MIPS Measures Relevant to Emergency Medicine

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

    066
    NQF:
    eMeasure ID:

    CMS146v6
    High Priority:

    Yes

    #066: Appropriate Testing for Children with Pharyngitis

    Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Pediatrics
    • Urgent Care
    ID:

    091
    NQF:

    0653
    eMeasure ID:
    High Priority:

    Yes

    #091: Acute Otitis Externa (AOE): Topical Therapy

    Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:

    093
    NQF:

    0654
    eMeasure ID:
    High Priority:

    Yes

    #093: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

    Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:

    107
    NQF:

    0104
    eMeasure ID:

    CMS161v6
    High Priority:

    No

    #107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

    Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Mental/Behavioral Health
    ID:

    116
    NQF:

    0058
    eMeasure ID:
    High Priority:

    Yes

    #116: Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

    The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Preventive Medicine
    • Urgent Care
    ID:

    187
    NQF:
    eMeasure ID:
    High Priority:

    No

    #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy

    Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Neurosurgery
    ID:

    254
    NQF:

    0651
    eMeasure ID:
    High Priority:

    No

    #254: Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

    Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    ID:

    255
    NQF:
    eMeasure ID:
    High Priority:

    No

    #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

    Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED)

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency 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:

    331
    NQF:
    eMeasure ID:
    High Priority:

    No

    #331: Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)

    Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:

    332
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

    Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:

    333
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #333: Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)

    Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:

    415
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

    Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care clinician who have an indication for a head CT

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Emergency Medicine
    ID:

    416
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years

    Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Emergency Medicine
    • *These measures (plus EHR-only measure 107) make-up the Emergency Medicine 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.  There are over 90 possible measures to choose from. The following are suggestions only:

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