- 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. Information about EMA (what happens if you report less than 6 measures) can be found here. Suggestions for your specialty include, but are not limited to, the following:
ID:044NQF:0236eMeasure ID:High Priority:No
2021 MIPS Measure #044: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.Measure Type
ID:076NQF:eMeasure ID:High Priority:Yes
- Thoracic Surgery
2021 MIPS Measure #076: Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followedMeasure Type
ID:404NQF:eMeasure ID:High Priority:Yes
- Interventional Radiology
2021 MIPS Measure #404: Anesthesiology Smoking Abstinence
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedureMeasure Type
- Intermediate Outcome
ID:424NQF:2671eMeasure ID:High Priority:Yes
2021 MIPS Measure #424: Perioperative Temperature Management
Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end timeMeasure Type
ID:430NQF:eMeasure ID:High Priority:Yes
2021 MIPS Measure #430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperativelyMeasure Type
ID:463NQF:eMeasure ID:High Priority:Yes
2021 MIPS Measure #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperativelyMeasure Type
ID:477NQF:eMeasure ID:High Priority:Yes
2021 MIPS Measure #477: Multimodal Pain Management
Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicineMeasure Type
- 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 90 possible measures 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_PSPA_6 - Consultation of the Prescription Drug Monitoring program (high weighted).
- IA_BE_15 - Engagement of patients, family and caregivers in developing a plan of care (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_PSPA_8 - Use of patient safety tools (medium weighted).