MIPS Measures Relevant to Plastic 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:

    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:

    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:

    355
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #355: Unplanned Reoperation within the 30 Day Postoperative Period

    Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Surgery
    • Plastic Surgery
    ID:

    356
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #356: Unplanned Hospital Readmission within 30 Days of Principal Procedure

    Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Surgery
    • Plastic Surgery
    ID:

    357
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #357: Surgical Site Infection (SSI)

    Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Surgery
    • Otolaryngology
    • Plastic Surgery
    • Vascular 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
    • *These measures represent the Plastic Surgery 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:

Register with MDinteractive