MIPS Measures Relevant to Geriatrics

  1. 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:
    039
    NQF:
    0046
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #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
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Preventive Medicine
    • Rheumatology
    ID:
    047
    NQF:
    0326
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #047: Advance 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
    • Clinical Social Work
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Internal Medicine
    • Neurology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    048
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

    Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • Urology
    ID:
    050
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #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:
    CMS147v10
    High Priority:
    No

    2021 MIPS Measure #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
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Otolaryngology
    • Pediatrics
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    111
    NQF:
    0043
    eMeasure ID:
    CMS127v9
    High Priority:
    No

    2021 MIPS Measure #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
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Otolaryngology
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    130
    NQF:
    0419e
    eMeasure ID:
    CMS68v10
    High Priority:
    Yes

    2021 MIPS Measure #130: Documentation of Current Medications in the Medical Record

    Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Infectious Disease
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology/Hematology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:
    154
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #154: Falls: Risk Assessment

    Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    155
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #155: Falls: Plan of Care

    Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    181
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #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
    • Audiology
    • Clinical Social Work
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Nutrition/Dietician
    • Physical Therapy/Occupational Therapy
    • Skilled Nursing Facility
    • Speech/Language Pathology
    ID:
    238
    NQF:
    0022
    eMeasure ID:
    CMS156v9
    High Priority:
    Yes

    2021 MIPS Measure #238: Use of High-Risk Medications in the Elderly

    Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Ophthalmology
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    281
    NQF:
    2872e
    eMeasure ID:
    CMS149v9
    High Priority:
    No

    2021 MIPS Measure #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
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    282
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #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
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:
    283
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

    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
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    286
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

    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
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    288
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #288: Dementia: Education and Support of Caregivers for Patients with Dementia

    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
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    370
    NQF:
    0710
    eMeasure ID:
    CMS159v9
    High Priority:
    Yes

    2021 MIPS Measure #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
    • Clinical Social Work
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Pediatrics
    ID:
    455
    NQF:
    0213
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #455: Percentage of Patients who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)

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

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Geriatrics
    • Oncology/Hematology
    ID:
    476
    NQF:
    eMeasure ID:
    CMS771v2
    High Priority:
    Yes

    2021 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

    Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Geriatrics
    • Urology
     
  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, 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.
  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. 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:

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