MIPS Measures Relevant to Orthopedic Surgery

  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:

    024
    NQF:

    0045
    eMeasure ID:
    High Priority:

    Yes

    #024: Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older

    Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Orthopedic Surgery
    • 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:

    109
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #109: Osteoarthritis (OA): Function and Pain Assessment

    Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Orthopedic Surgery
    • Physical Medicine
    • 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:

    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:

    134
    NQF:

    0418
    eMeasure ID:

    CMS2v7
    High Priority:

    No

    #134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

    Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Orthopedic Surgery
    • Pediatrics
    • Preventive Medicine
    ID:

    154
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #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
    • Family Medicine
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    155
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #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
    • Family Medicine
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    178
    NQF:
    eMeasure ID:
    High Priority:

    No

    #178: Rheumatoid Arthritis (RA): Functional Status Assessment

    Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    • Rheumatology
    ID:

    179
    NQF:
    eMeasure ID:
    High Priority:

    No

    #179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

    Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    • Rheumatology
    ID:

    180
    NQF:
    eMeasure ID:
    High Priority:

    No

    #180: Rheumatoid Arthritis (RA): Glucocorticoid Management

    Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    • Rheumatology
    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:

    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:

    318
    NQF:

    0101
    eMeasure ID:

    CMS139v6
    High Priority:

    No

    #318: Falls: Screening for Future Fall Risk

    Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Orthopedic Surgery
    • Podiatry
    ID:

    350
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #350: Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

    Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    351
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #351: Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

    Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    352
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #352: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet

    Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    353
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #353: Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report

    Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    358
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #358: Patient-centered Surgical Risk Assessment and Communication

    Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

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

    375
    NQF:
    eMeasure ID:

    CMS66v6
    High Priority:

    Yes

    #375: Functional Status Assessment for Total Knee Replacement

    Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    376
    NQF:
    eMeasure ID:

    CMS56v6
    High Priority:

    Yes

    #376: Functional Status Assessment for Total Hip Replacement

    Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic 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:

    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:

    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:

    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:

    470
    NQF:

    2653
    eMeasure ID:
    High Priority:

    Yes

    #470: Average Change In Functional Status Following Total Knee Replacement Surgery

    The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement

    Measure Type
    • Outcome
    Specifications
    Specialty
    • 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 (plus EHR-only measures 318, 375 and 376) make up the Orthopedic Surgery 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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