- Quality - 65% of total score: Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to possibly earn more than 3 points on a measure. Note: Small practices (less than 16 in the practice) can earn 3 points on a measure if at least 1 eligible case is reported. Suggestions for your specialty include, but are not limited to, the following: ID:126NQF:0417eMeasure ID:High Priority:No
2021 MIPS Measure #126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months
Measure Type- Process
SpecificationsSpecialty- Endocrinology
- Family Medicine
- Internal Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
ID:127NQF:0416eMeasure ID:High Priority:No2021 MIPS Measure #127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing
Measure Type- Process
SpecificationsSpecialty- Physical Therapy/Occupational Therapy
- Podiatry
ID:128NQF:0421eMeasure ID:CMS69v9High Priority:No2021 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters
Measure Type- Process
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nutrition/Dietician
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
- Vascular Surgery
ID:130NQF:0419eeMeasure ID:CMS68v10High Priority:Yes2021 MIPS Measure #130: Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
Measure Type- Process
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- Clinical Social Work
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Geriatrics
- Hospitalists
- Infectious Disease
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Neurosurgery
- Nutrition/Dietician
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Preventive Medicine
- Pulmonology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:134NQF:0418eMeasure ID:CMS2v10High Priority:No2021 MIPS Measure #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter
Measure Type- Process
Specialty- Audiology
- Clinical Social Work
- Endocrinology
- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Orthopedic Surgery
- Pediatrics
- Physical Therapy/Occupational Therapy
- Preventive Medicine
- Speech/Language Pathology
ID:154NQF:0101eMeasure ID:High Priority:Yes2021 MIPS Measure #154: Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
Measure Type- Process
SpecificationsSpecialty- Audiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Neurology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Skilled Nursing Facility
ID:155NQF:0101eMeasure ID:High Priority:Yes2021 MIPS Measure #155: Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
Measure Type- Process
SpecificationsSpecialty- Audiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Neurology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Skilled Nursing Facility
ID:181NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #181: Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Measure Type- Process
SpecificationsSpecialty- Audiology
- Clinical Social Work
- Family Medicine
- Geriatrics
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Nutrition/Dietician
- Physical Therapy/Occupational Therapy
- Skilled Nursing Facility
- Speech/Language Pathology
ID:182NQF:2624eMeasure ID:High Priority:Yes2021 MIPS Measure #182: Functional Outcome Assessment
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
Measure Type- Process
SpecificationsSpecialty- Audiology
- Chiropractic Medicine
- Family Medicine
- Nephrology
- Orthopedic Surgery
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Preventive Medicine
- Speech/Language Pathology
ID:217NQF:0422eMeasure ID:High Priority:Yes2021 MIPS Measure #217: Functional Status Change for Patients with Knee Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM) . The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
ID:218NQF:0423eMeasure ID:High Priority:Yes2021 MIPS Measure #218: Functional Status Change for Patients with Hip Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM) . The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
ID:219NQF:0424eMeasure ID:High Priority:Yes2021 MIPS Measure #219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF)patient- reported outcome measure (PROM) . The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
ID:220NQF:0425eMeasure ID:High Priority:Yes2021 MIPS Measure #220: Functional Status Change for Patients with Low Back Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the FOTO Low Back FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
ID:221NQF:0426eMeasure ID:High Priority:Yes2021 MIPS Measure #221: Functional Status Change for Patients with Shoulder Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the FOTO Shoulder FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
ID:222NQF:0427eMeasure ID:High Priority:Yes2021 MIPS Measure #222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with elbow, wrist, or hand impairments. The change in functional status (FS) is assessed using the FOTO Elbow/Wrist/Hand FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
ID:226NQF:0028eMeasure ID:CMS138v9High Priority:No2021 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user
Measure Type- Process
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- Clinical Social Work
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Neurosurgery
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:281NQF:2872eeMeasure ID:CMS149v9High Priority:No2021 MIPS Measure #281: Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:283NQF:eMeasure ID:High Priority:No2021 MIPS Measure #283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:286NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:288NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #288: Dementia: Education and Support of Caregivers for Patients with Dementia
Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:318NQF:0101eMeasure ID:CMS139v9High Priority:Yes2021 MIPS Measure #318: Falls: Screening for Future Fall Risk
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
Measure Type- Process
SpecificationsSpecialty- Audiology
- Family Medicine
- Internal Medicine
- Nephrology
- Orthopedic Surgery
- Otolaryngology
- Physical Therapy/Occupational Therapy
- Podiatry
ID:478NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #478: Functional Status Change for Patients with Neck Impairments
This is a patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paper-pencil).
Measure Type- Outcome
SpecificationsSpecialty- Chiropractic Medicine
- Orthopedic Surgery
- Physical Therapy/Occupational Therapy
- IA: Improvement Activities - 15% of total score: Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. A group can attest to an activity when at least 50% of the clinicians in the group perform the same activity during any continuous 90-day period (or as specified in the activity description) in the same performance year. There are over 100 possible activities to choose from. The following are suggestions only:
- IA_AHE_6 -Provide Education Opportunities for New Clinicians (high weighted).
- IA_BE_6 -Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (high weighted).
- IA_BE_15 -Engagement of Patients, Family, and Caregivers in Developing a Plan of Care (medium weighted).
- IA_BE_25-Drug Cost Transparency (high weighted).
- IA_PM_15 - Implementation of episodic care management practice improvements (medium weighted).
- IA_PSPA_17 -Implementation of analytic capabilities to manage total cost of care for practice population (medium weighted).
- IA_PSPA_19 - Implementation of formal quality improvement methods, practice changes or other practice improvement processes (medium weighted).
- IA_CC_9-Implementation of practices/processes for developing regular individual care plans (medium weighted).
- IA_CC_18 - Relationship-Centered Communication (medium weighted).