MIPS Measures Relevant to Geriatrics

  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:

    039
    NQF:

    0046
    eMeasure ID:
    High Priority:

    No

    #039: Screening for Osteoporosis for Women Aged 65-85 Years of Age

    Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis

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

    046
    NQF:

    0097
    eMeasure ID:
    High Priority:

    Yes

    #046: Medication Reconciliation Post-Discharge

    The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years of age and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record

    This measure is submitted as three rates stratified by age group:

    • Submission Criteria 1: 18-64 years of age
    • Submission Criteria 2: 65 years and older
    • Total Rate: All patients 18 years of age and older
    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Geriatrics
    • Nephrology
    • Orthopedic Surgery
    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:

    050
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

    Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Urology
    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:

    111
    NQF:

    0043
    eMeasure ID:

    CMS127v6
    High Priority:

    No

    #111: Pneumococcal Vaccination Status for Older Adults

    Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

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

    131
    NQF:

    0420
    eMeasure ID:
    High Priority:

    Yes

    #131: Pain Assessment and Follow-Up

    Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

    Measure Type
    • Process
    Specifications
    Specialty
    • Geriatrics
    • Orthopedic Surgery
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Rheumatology
    • Urgent Care
    • Urology
    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:

    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:

    281
    NQF:

    2872
    eMeasure ID:

    CMS149v6
    High Priority:

    No

    #281: Dementia: Cognitive Assessment

    Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

    Measure Type
    • Process
    Specifications
    Specialty
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    282
    NQF:
    eMeasure ID:
    High Priority:

    No

    #282: Dementia: Functional Status Assessment

    Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    283
    NQF:
    eMeasure ID:
    High Priority:

    No

    #283: Dementia: Neuropsychiatric Symptom Assessment

    Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    286
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #286: Dementia: Counseling Regarding Safety Concerns

    Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources

    Measure Type
    • Process
    Specifications
    Specialty
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    288
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #288: Dementia: Caregiver Education and Support

    Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    370
    NQF:

    0710
    eMeasure ID:

    CMS159v6
    High Priority:

    Yes

    #370: Depression Remission at Twelve Months

    The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    ID:

    408
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #408: Opioid Therapy Follow-up Evaluation

    All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    412
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #412: Documentation of Signed Opioid Treatment Agreement

    All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    414
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #414: Evaluation or Interview for Risk of Opioid Misuse

    All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    455
    NQF:

    0213
    eMeasure ID:
    High Priority:

    Yes

    #455: Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life

    Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Oncology
    • Geriatrics
    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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