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MIPS Measures Relevant to Pulmonary Medicine

  1. 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:
    047
    NQF:
    0326
    eMeasure 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
    Specifications
    Specialty
    • Cardiology
    • Clinical Social Work
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Internal Medicine
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    052
    NQF:
    0102
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #052: Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy

    Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator

    Measure Type
    • Process
    Specifications
    Specialty
    • Pulmonology
    ID:
    110
    NQF:
    0041
    eMeasure ID:
    CMS147v10
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Obstetrics/Gynecology
    • Oncology
    • Otolaryngology
    • Pediatrics
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    111
    NQF:
    0043
    eMeasure ID:
    CMS127v9
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Oncology
    • Otolaryngology
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    128
    NQF:
    0421
    eMeasure ID:
    CMS69v9
    High Priority:
    No

    2021 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
    Specifications
    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:
    130
    NQF:
    0419e
    eMeasure ID:
    CMS68v10
    High Priority:
    Yes

    2021 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
    Specifications
    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
    • 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:
    226
    NQF:
    0028
    eMeasure ID:
    CMS138v9
    High Priority:
    No

    2021 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
    Specifications
    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
    • 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:
    236
    NQF:
    0018
    eMeasure ID:
    CMS165v9
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Pulmonology
    • Rheumatology
    • Vascular Surgery
    ID:
    238
    NQF:
    0022
    eMeasure ID:
    CMS156v9
    High Priority:
    Yes

    2021 MIPS Measure #238: Use of High-Risk Medications in the Elderly

    Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Ophthalmology
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    ID:
    277
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #277: Sleep Apnea: Severity Assessment at Initial Diagnosis

    Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

    Measure Type
    • Process
    Specifications
    Specialty
    • Internal Medicine
    • Neurology
    • Otolaryngology
    • Pulmonology
    ID:
    279
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

    Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured

    Measure Type
    • Process
    Specifications
    Specialty
    • Internal Medicine
    • Neurology
    • Otolaryngology
    • Pulmonology
    ID:
    374
    NQF:
    eMeasure ID:
    CMS50v9
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:
    398
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #398: Optimal Asthma Control

    Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Pulmonology
    ID:
    431
    NQF:
    2152
    eMeasure ID:
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Cardiology
    • Clinical Social Work
    • Family Medicine
    • Gastroenterology
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Urgent Care
    • Urology
    ID:
    444
    NQF:
    1799
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #444: Medication Management for People with Asthma

    The percentage of patients 5-64 years of age during the performance period who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Internal Medicine
    • Pediatrics
    • Pulmonology
     
  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, 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.
  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. 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:

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