- 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:047NQF:0326eMeasure 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
SpecificationsSpecialty- 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:048NQF:eMeasure ID:High Priority:No2021 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
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- Urology
ID:050NQF:eMeasure ID:High Priority:Yes2021 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
SpecificationsSpecialty- Family Medicine
- Geriatrics
- Internal Medicine
- Obstetrics/Gynecology
- Urology
ID:110NQF:0041eMeasure ID:CMS147v10High Priority:No2021 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
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:111NQF:0043eMeasure ID:CMS127v9High Priority:No2021 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
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:112NQF:2372eMeasure ID:CMS125v9High Priority:No2021 MIPS Measure #112: Breast Cancer Screening
Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period
Measure Type- Process
Specialty- Family Medicine
- Obstetrics/Gynecology
- Preventive Medicine
ID:128NQF:0421eMeasure ID:CMS69v9High Priority:No2021 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters
Measure Type- Process
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nutrition/Dietician
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
- Vascular Surgery
ID:130NQF:0419eeMeasure ID:CMS68v10High Priority:Yes2021 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
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:226NQF:0028eMeasure ID:CMS138v9High Priority:No2021 MIPS Measure #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 12 months AND who received tobacco cessation intervention if identified as a tobacco user
Measure Type- Process
Specialty- Allergy/Immunology
- Audiology
- Cardiology
- Clinical Social Work
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Neurosurgery
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Plastic Surgery
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Speech/Language Pathology
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
ID:236NQF:0018eMeasure ID:CMS165v9High Priority:Yes2021 MIPS Measure #236: Controlling High Blood Pressure
Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period
Measure Type- Intermediate Outcome
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
- Pulmonology
- Rheumatology
- Vascular Surgery
ID:265NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #265: Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient
Measure Type- Process
SpecificationsSpecialty- Dermatology
- Obstetrics/Gynecology
- Otolaryngology
- Urology
ID:309NQF:eMeasure ID:CMS124v9High Priority:No2021 MIPS Measure #309: Cervical Cancer Screening
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
* Women age 21-64 who had cervical cytology performed every 3 years
* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 yearsMeasure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
ID:310NQF:eMeasure ID:CMS153v9High Priority:No2021 MIPS Measure #310: Chlamydia Screening for Women
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
Measure Type- Process
SpecificationsSpecialty- Obstetrics/Gynecology
- Pediatrics
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:335NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #335: Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)
Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries by cesarean section (C-section), or early inductions of labor, without medical indication.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
ID:336NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #336: Maternity Care: Postpartum Follow-up and Care Coordination
Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 8 weeks of giving birth and received the following at a postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update
Measure Type- Process
SpecificationsSpecialty- Obstetrics/Gynecology
ID:374NQF:eMeasure ID:CMS50v9High Priority:Yes2021 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
Measure Type- Process
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Interventional Radiology
- Mental/Behavioral Health
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:402NQF:2803eMeasure ID:High Priority:No2021 MIPS Measure #402: Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user
Measure Type- Process
SpecificationsSpecialty- Allergy/Immunology
- Cardiology
- Clinical Social Work
- Dermatology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Pediatrics
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urgent Care
- Vascular Surgery
ID:418NQF:0053eMeasure ID:High Priority:No2021 MIPS Measure #418: Osteoporosis Management in Women Who Had a Fracture
The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture
Measure Type- Process
SpecificationsSpecialty- Endocrinology
- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
- Orthopedic Surgery
ID:422NQF:2063eMeasure ID:High Priority:Yes2021 MIPS Measure #422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
Measure Type- Process
SpecificationsSpecialty- Obstetrics/Gynecology
ID:429NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #429: Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy
Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse
Measure Type- Process
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:431NQF:2152eMeasure ID:High Priority:No2021 MIPS Measure #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user
Measure Type- Process
SpecificationsSpecialty- Cardiology
- Clinical Social Work
- Family Medicine
- Gastroenterology
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Nutrition/Dietician
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Urgent Care
- Urology
ID:432NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:433NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:434NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #434: Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery.
Measure Type- Outcome
SpecificationsSpecialty- Obstetrics/Gynecology
- Urology
ID:443NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #443: Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
ID:448NQF:0567eMeasure ID:High Priority:Yes2021 MIPS Measure #448: Appropriate Workup Prior to Endometrial Ablation
Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation
Measure Type- Process
SpecificationsSpecialty- Obstetrics/Gynecology
ID:472NQF:eMeasure ID:CMS249v3High Priority:Yes2021 MIPS Measure #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
ID:475NQF:eMeasure ID:CMS349v3High Priority:No2021 MIPS Measure #475: HIV Screening
Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Infectious Disease
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- *These measures represent the Obstetrics/Gynecology Specialty Measures Set.
- 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 100 possible activities to choose from. The following are suggestions only:
- IA_AHE_6 - Provide Education Opportunities for New Clinicians (high weighted).
- IA_BE_6 - Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (high weighted).
- IA_BE_15 - Engagement of Patients, Family, and Caregivers in Developing a Plan of Care (medium weighted).
- IA_PM_5-Engagement of community for health status improvement (medium weighted).
- IA_PM_6-Use of toolsets or other resources to close healthcare disparities across communities (medium weighted).
- IA_PM_11-Regular Review Practices in Place on Targeted Patient Population Needs (medium weighted).
- IA_PM_15-Implementation of episodic care management practice improvements (medium weighted).
- IA_PM_21-Advance Care Planning (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_19- Implementation of formal quality improvement methods, practice changes, or other practice improvement processes (medium weighted).
- IA_PSPA_22- Implementation of formal quality improvement methods, practice changes, or other practice improvement processes (high weighted).
- IA_PSPA_31- Patient Medication Risk Education (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).