MIPS Measures Relevant to Cardiology

  1. Quality - 45% of total score:  Report 6 measures, including one Outcome or one high priority measure 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:

    005
    NQF:

    0081
    eMeasure ID:

    CMS135v6
    High Priority:

    No

    #005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) 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 ACE inhibitor or ARB 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
    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:

    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:

    128
    NQF:

    0421
    eMeasure ID:

    CMS69v6
    High Priority:

    No

    #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 during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Rheumatology
    • Urology
    • Vascular Surgery
    ID:

    130
    NQF:

    0419
    eMeasure ID:

    CMS68v7
    High Priority:

    Yes

    #130: Documentation of Current Medications in the Medical Record

    Percentage of visits for patients aged 18 years and older for which the MIPS eligible professional or MIPS eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Infectious Disease
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:

    226
    NQF:

    0028
    eMeasure ID:

    CMS138v6
    High Priority:

    No

    #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 24 months AND who received tobacco cessation intervention if identified as a tobacco user

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

    236
    NQF:

    0018
    eMeasure ID:

    CMS165v6
    High Priority:

    Yes

    #236: Controlling High Blood Pressure

    Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Rheumatology
    • Vascular Surgery
    ID:

    238
    NQF:

    0022
    eMeasure ID:

    CMS156v6
    High Priority:

    Yes

    #238: Use of High-Risk Medications in the Elderly

    Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.

    1) Percentage of patients who were ordered at least one high-risk medication.
    2) Percentage of patients who were ordered at least two of the same high-risk medication

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Rheumatology
    ID:

    243
    NQF:

    0643
    eMeasure ID:
    High Priority:

    Yes

    #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting

    Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    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:

    322
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #322: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients

    Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Cardiology
    ID:

    323
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #323: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)

    Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Cardiology
    ID:

    324
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #324: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

    Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Cardiology
    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:

    344
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

    Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Cardiology
    • Vascular Surgery
    ID:

    345
    NQF:

    1543
    eMeasure ID:
    High Priority:

    Yes

    #345: Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive

    Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Cardiology
    • Neurosurgery
    • Vascular Surgery
    ID:

    374
    NQF:
    eMeasure ID:

    CMS50v6
    High Priority:

    Yes

    #374: Closing the Referral Loop: Receipt of Specialist Report

    Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    402
    NQF:
    eMeasure ID:
    High Priority:

    No

    #402: Tobacco Use and Help with Quitting Among Adolescents

    The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

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

    431
    NQF:

    2152
    eMeasure ID:
    High Priority:

    No

    #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 24 months AND who received brief counseling if identified as an unhealthy alcohol user

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Urgent Care
    • Urology
    ID:

    438
    NQF:
    eMeasure ID:

    CMS347v1
    High Priority:

    No

    #438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

    Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:

    • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
    • Adults aged ≥ 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
    • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Preventive Medicine
    ID:

    441
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

    The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:

    • Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND
    • Most recent tobacco status is Tobacco Free -- AND
    • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND
    • Statin Use Unless Contraindicated

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Vascular Surgery
    ID:

    442
    NQF:

    0071
    eMeasure ID:
    High Priority:

    No

    #442: Persistence of Beta-Blocker Treatment After a Heart Attack

    The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
     
    • *These  registry measures make-up the Cardiology Specialty Measures set. 
  2. 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.
  3. 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:

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