MIPS Measures Relevant to Obstetrics and Gynecology

  1. Quality - 45% of total score:  Report 6 measures, including one Outcome or one 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:

    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:

    048
    NQF:
    eMeasure ID:
    High Priority:

    No

    #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
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • Urology
    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:

    112
    NQF:

    2372
    eMeasure ID:

    CMS125v6
    High Priority:

    No

    #112: Breast Cancer Screening

    Percentage of women 51 - 74 years of age who had a mammogram to screen for breast cancer

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    ID:

    128
    NQF:

    0421
    eMeasure ID:

    CMS69v6
    High Priority:

    No

    #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 during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Rheumatology
    • 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:

    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:

    236
    NQF:

    0018
    eMeasure ID:

    CMS165v6
    High Priority:

    Yes

    #236: Controlling High Blood Pressure

    Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Rheumatology
    • Vascular Surgery
    ID:

    265
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Dermatology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Urology
    ID:

    309
    NQF:

    0032
    eMeasure ID:

    CMS124v6
    High Priority:

    No

    #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 years

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

    310
    NQF:

    0033
    eMeasure ID:

    CMS153v6
    High Priority:

    No

    #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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Pediatrics
    ID:

    317
    NQF:
    eMeasure ID:

    CMS22v6
    High Priority:

    No

    #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Plastic Surgery
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:

    374
    NQF:
    eMeasure ID:

    CMS50v6
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    402
    NQF:
    eMeasure ID:
    High Priority:

    No

    #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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urgent Care
    • Vascular Surgery
    ID:

    418
    NQF:

    0053
    eMeasure ID:
    High Priority:

    No

    #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
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    ID:

    422
    NQF:

    2063
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    ID:

    428
    NQF:
    eMeasure ID:
    High Priority:

    No

    #428: Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

    Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines

    Measure Type
    • Process
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:

    429
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:

    431
    NQF:

    2152
    eMeasure ID:
    High Priority:

    No

    #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 24 months AND who received brief counseling if identified as an unhealthy alcohol user

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Urgent Care
    • Urology
    ID:

    432
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

    Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 30 days after surgery

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:

    433
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:

    434
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #434: Proportion of Patients Sustaining a Ureter Injury at the Time of any 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
    Specifications
    Specialty
    • Obstetrics/Gynecology
    • Urology
    ID:

    443
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:

    448
    NQF:

    0567
    eMeasure ID:
    High Priority:

    Yes

    #448: Appropriate Workup Prior to Endometrial Ablation

    Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation

    Measure Type
    • Process
    Specifications
    Specialty
    • Obstetrics/Gynecology
    ID:

    472
    NQF:
    eMeasure ID:

    CMS249v1
    High Priority:

    No

    #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
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:

    475
    NQF:
    eMeasure ID:

    CMS349v1
    High Priority:

    No

    #475: HIV Screening

    Percentage of patients 15-65 years of age who have been tested for HIV within that age range

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • *These measures represent the Obstetrics/Gynecology 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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