- Quality - 40% 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:066NQF:eMeasure ID:CMS146v9High Priority:Yes
2021 MIPS Measure #066: Appropriate Testing for Pharyngitis
The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test
Measure Type- Process
Specialty- Emergency Medicine
- Family Medicine
- Pediatrics
- Urgent Care
ID:093NQF:0654eMeasure ID:High Priority:Yes2021 MIPS Measure #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
SpecificationsSpecialty- Emergency Medicine
- Family Medicine
- Internal Medicine
- Otolaryngology
- Pediatrics
- Urgent Care
ID:107NQF:0104eeMeasure ID:CMS161v9High Priority:No2021 MIPS Measure #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
SpecificationsSpecialty- Emergency Medicine
- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
ID:116NQF:0058eMeasure ID:High Priority:Yes2021 MIPS Measure #116: Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.
Measure Type- Process
SpecificationsSpecialty- Emergency Medicine
- Family Medicine
- Internal Medicine
- Pediatrics
- Preventive Medicine
- Urgent Care
ID:187NQF:eMeasure ID:High Priority:No2021 MIPS Measure #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 alteplase was initiated within three hours of time last known well
Measure Type- Process
SpecificationsSpecialty- Emergency Medicine
- Neurosurgery
ID:254NQF:0651eMeasure ID:High Priority:No2021 MIPS Measure #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
SpecificationsSpecialty- Emergency Medicine
ID:317NQF:eMeasure ID:CMS22v9High Priority:No2021 MIPS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is pre-hypertensive or hypertensive
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Emergency Medicine
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Plastic Surgery
- Preventive Medicine
- Rheumatology
- Skilled Nursing Facility
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:331NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral 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
SpecificationsSpecialty- Allergy/Immunology
- Emergency Medicine
- Family Medicine
- Internal Medicine
- Otolaryngology
- Urgent Care
ID:332NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #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
SpecificationsSpecialty- Allergy/Immunology
- Emergency Medicine
- Family Medicine
- Internal Medicine
- Otolaryngology
- Urgent Care
ID:415NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #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 provider who have an indication for a head CT
Measure Type- Efficiency
SpecificationsSpecialty- Emergency Medicine
ID:416NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #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
SpecificationsSpecialty- Emergency Medicine
- 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, 2021. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 65% of your score.
- e-Prescribing
- Query of Prescription Drug Monitoring Program (PDMP) (optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops by Sending Health Information
- Support Electronic Referral Loops by Receiving and Incorporating Health Information
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- 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_BE_6 -Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (high weighted).
- IA_BE_7 -Participation in a QCDR, that promotes use of patient engagement tools (medium weighted).
- IA_CC_12 - Care coordination agreements that promote improvements in patient tracking across settings (medium weighted).
- IA_PSPA_1 - Participation in an AHRQ-listed patient safety organization. (medium weighted).
- IA_PSPA_6 - Consultation of the Prescription Drug Monitoring Program (high weighted).
- IA_PSPA_17 - Implementation of analytic capabilities to manage total cost of care for practice population (medium weighted).
- IA_PSPA_26 - Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event (medium-weighted).
- IA_PSPA_32 -Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support (high weighted).
