- 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:001NQF:0059eMeasure ID:CMS122v9High Priority:Yes
2021 MIPS Measure #001: Diabetes: Hemoglobin A1c Poor Control
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Measure Type- Intermediate Outcome
Specialty- Endocrinology
- Family Medicine
- Internal Medicine
- Nephrology
- Nutrition/Dietician
- Preventive Medicine
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
- 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: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:431NQF:2152eMeasure ID:High Priority:No2021 MIPS Measure #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Clinical Social Work
- Family Medicine
- Gastroenterology
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Nutrition/Dietician
- Obstetrics/Gynecology
- Oncology
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Urgent Care
- Urology
- 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_EPA_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_AHE_1 - Engagement of new Medicaid patients and follow-up (high weighted).
- IA_BE_14 - Engage patients and families to guide improvement in the system of care (high weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- IA_PM_4 - Glycemic management services (high-weighted).
- IA_PM_20 - Glycemic Referring Services (medium weighted).
- IA_PM_19 - Glycemic Screening Services (medium weighted).
- IA_CC_1 - Implementation of use of specialist reports back to referring clinician or group to close referral loop (medium weighted).
- IA_CC_7 - Regular training in care coordination (medium weighted).
- IA_CC_9 - Implementation of practices/processes for developing regular individual care plans (medium weighted).
- IA_CC_10 - Care transition documentation practice improvements (medium weighted).
- IA_CC_11 - Care transition standard operational improvements (medium weighted).
- IA_CC_12 - Care coordination agreements that promote improvements in patient tracking across settings (medium weighted).
- IA_EPA_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_EPA_5 - Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/) (medium weighted).
- IA_BE_5 - Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities (medium weighted).
- A_BE_15 - Engagement of patients, family and caregivers in developing a plan of care (medium weighted).
- IA_BE_16 - Evidenced-based techniques to promote self-management into usual care (medium weighted).
- IA_BE_17 - Use of tools to assist patient self-management (medium weighted).
- IA_BE_21 - Improved practices that disseminate appropriate self-management materials (medium weighted).
- IA_PSPA_19 - Implementation of formal quality improvement methods, practice changes or other practice improvement processes (medium weighted).
- IA_PSPA_1 - Participation in an AHRQ-listed patient safety organization. (medium weighted).
- IA_PSPA_11 - Participation in CAHPS or other supplemental questionnaire (high-weighted).
- IA_PM_5 - Engagement of community for health status improvement (medium weighted).
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