MIPS Measures Relevant to Skilled Nursing Facilities

  1. Quality - 45% of total score:  Report 6 measures, including one Outcome (or high priority measure if outcome not available) for 12 months. To earn 1 or 3 points on a measure report at least one eligible case. To earn more than 3 points on a measure report at least 60 percent of eligible cases.  Suggestions for your specialty include but are not limited to the following:

    ID:

    006
    NQF:

    0067
    eMeasure ID:
    High Priority:

    No

    #006: Coronary Artery Disease (CAD): Antiplatelet Therapy

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Skilled Nursing Facility
    ID:

    007
    NQF:

    0070
    eMeasure ID:

    CMS145v6
    High Priority:

    No

    #007: Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Skilled Nursing Facility
    ID:

    008
    NQF:

    0083
    eMeasure ID:

    CMS144v6
    High Priority:

    No

    #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

    Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Hospitalists
    • Internal Medicine
    • Skilled Nursing Facility
    ID:

    047
    NQF:

    0326
    eMeasure ID:
    High Priority:

    Yes

    #047: Care Plan

    Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Internal Medicine
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    110
    NQF:

    0041
    eMeasure ID:

    CMS147v7
    High Priority:

    No

    #110: Preventive Care and Screening: Influenza Immunization

    Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Oncology
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Pediatrics
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    ID:

    118
    NQF:

    0066
    eMeasure ID:
    High Priority:

    No

    #118: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Skilled Nursing Facility
    ID:

    154
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    155
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    181
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Skilled Nursing Facility
    ID:

    317
    NQF:
    eMeasure ID:

    CMS22v6
    High Priority:

    No

    #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Plastic Surgery
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:

    326
    NQF:

    1525
    eMeasure ID:
    High Priority:

    No

    #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

    Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Skilled Nursing Facility
    ID:

    474
    NQF:
    eMeasure ID:
    High Priority:

    No

    #474: Zoster (Shingles) Vaccination

    The percentage of patients aged 50 years and older who have had the Shingrix zoster (shingles) vaccination

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Oncology
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Preventive Medicine
    • Skilled Nursing Facility
    • PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 2019. There are exclusions available for most of the 11 measures that are reported. Please check your QPP Participation Status to see if you are exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category.
    • 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.  There are over 90 possible measures to choose from. The following are suggestions only:

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