MIPS Measures Relevant to Neurosurgery

  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:

    021
    NQF:

    0268
    eMeasure ID:
    High Priority:

    Yes

    #021: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin

    Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Neurosurgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Vascular Surgery
    ID:

    023
    NQF:

    0239
    eMeasure ID:
    High Priority:

    Yes

    #023: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

    Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Neurosurgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • 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:

    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:

    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:

    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:

    346
    NQF:

    1540
    eMeasure ID:
    High Priority:

    Yes

    #346: Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive

    Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery

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

    409
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #409: Clinical Outcome Post Endovascular Stroke Treatment

    Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Interventional Radiology
    • Neurosurgery
    ID:

    413
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #413: Door to Puncture Time for Endovascular Stroke Treatment

    Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Interventional Radiology
    • Neurosurgery
    ID:

    459
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #459: Average Change in Back Pain following Lumbar Discectomy / Laminotomy

    The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    460
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #460: Average Change in Back Pain following Lumbar Fusion

    The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had a lumbar fusion procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    461
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #461: Average Change in Leg Pain following Lumbar Discectomy / Laminotomy

    The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    469
    NQF:

    2643
    eMeasure ID:
    High Priority:

    Yes

    #469: Average Change in Functional Status Following Lumbar Fusion Surgery

    The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients 18 years of age and older who had a lumbar fusion procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    471
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #471: Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery

    The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    473
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #473: Average Change in Leg Pain Following Lumbar Fusion Surgery

    The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    • *These measures represent the Neurosurgery 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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