- 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:009NQF:eMeasure ID:CMS128v9High Priority:No
2021 MIPS Measure #009: Anti-Depressant Medication Management
Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported:
- Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks)
- Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
ID:107NQF:0104eeMeasure ID:CMS161v9High Priority:No2021 MIPS Measure #107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
Measure Type- Process
SpecificationsSpecialty- Emergency Medicine
- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
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:134NQF:0418eMeasure ID:CMS2v10High Priority:No2021 MIPS Measure #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to 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 eligible encounter
Measure Type- Process
Specialty- Audiology
- Clinical Social Work
- Endocrinology
- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Orthopedic Surgery
- Pediatrics
- Physical Therapy/Occupational Therapy
- Preventive Medicine
- Speech/Language Pathology
ID:181NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #181: Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Measure Type- Process
SpecificationsSpecialty- Audiology
- Clinical Social Work
- Family Medicine
- Geriatrics
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Nutrition/Dietician
- Physical Therapy/Occupational Therapy
- Skilled Nursing Facility
- Speech/Language Pathology
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:281NQF:2872eeMeasure ID:CMS149v9High Priority:No2021 MIPS Measure #281: Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:282NQF:eMeasure ID:High Priority:No2021 MIPS Measure #282: Dementia: Functional Status Assessment
Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
ID:283NQF:eMeasure ID:High Priority:No2021 MIPS Measure #283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:286NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
ID:288NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #288: Dementia: Education and Support of Caregivers for Patients with Dementia
Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Geriatrics
- Mental/Behavioral Health
- Neurology
- Physical Therapy/Occupational Therapy
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:366NQF:eMeasure ID:CMS136v10High Priority:No2021 MIPS Measure #366: Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.
a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.Measure Type- Process
SpecificationsSpecialty- Mental/Behavioral Health
- Pediatrics
ID:370NQF:0710eMeasure ID:CMS159v9High Priority:Yes2021 MIPS Measure #370: Depression Remission at Twelve Months
The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date
Measure Type- Outcome
Specialty- Clinical Social Work
- Family Medicine
- Geriatrics
- Internal Medicine
- Mental/Behavioral Health
- Pediatrics
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:382NQF:1365eeMeasure ID:CMS177v9High Priority:Yes2021 MIPS Measure #382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk
Measure Type- Process
SpecificationsSpecialty- Clinical Social Work
- Mental/Behavioral Health
- Pediatrics
ID:383NQF:1879eMeasure ID:High Priority:Yes2021 MIPS Measure #383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period
Measure Type- Intermediate Outcome
SpecificationsSpecialty- Clinical Social Work
- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
ID:391NQF:0576eMeasure ID:High Priority:Yes2021 MIPS Measure #391: Follow-Up After Hospitalization for Mental Illness (FUH)
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted:
- The percentage of discharges for which the patient received follow-up within 30 days after discharge
- The percentage of discharges for which the patient received follow-up within 7 days after discharge
Measure Type- Process
SpecificationsSpecialty- Internal Medicine
- Mental/Behavioral Health
- Pediatrics
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: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:468NQF:3175eMeasure ID:High Priority:Yes2021 MIPS Measure #468: Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Mental/Behavioral Health
- Physical Medicine
- 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 measures that are reported. 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 measures to choose from. The following are suggestions only:
- 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_BMH_5 -MDD prevention and treatment interventions (medium weighted).
- IA_BMH_6 -Implementation of co-location PCP and MH services (high weighted).
- IA_BMH_10 - Completion of Collaborative Care Management Training Program (medium weighted).
- IA_CC_18 - Relationship-Centered Communication (medium weighted).
- IA_PSPA_11 - Participation in CAHPS or other supplemental questionnaire (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).