MIPS Measures Relevant to Nephrology

  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:

    001
    NQF:

    0059
    eMeasure ID:

    CMS122v6
    High Priority:

    Yes

    #001: Diabetes: Hemoglobin A1c Poor Control

    Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Preventive Medicine
    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:

    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:

    119
    NQF:

    0062
    eMeasure ID:

    CMS134v6
    High Priority:

    No

    #119: Diabetes: Medical Attention for Nephropathy

    The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Preventive Medicine
    • Urology
    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:

    182
    NQF:

    2624
    eMeasure ID:
    High Priority:

    Yes

    #182: Functional Outcome Assessment

    Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

    Measure Type
    • Process
    Specifications
    Specialty
    • Nephrology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    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:

    328
    NQF:

    1667
    eMeasure ID:
    High Priority:

    Yes

    #328: Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL

    Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Nephrology
    ID:

    330
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #330: Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days

    Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Nephrology
    ID:

    400
    NQF:

    3059
    eMeasure ID:
    High Priority:

    No

    #400: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

    Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Nephrology
    ID:

    403
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #403: Adult Kidney Disease: Referral to Hospice

    Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care

    Measure Type
    • Process
    Specifications
    Specialty
    • Nephrology
    ID:

    474
    NQF:
    eMeasure ID:
    High Priority:

    No

    #474: Zoster (Shingles) Vaccination

    The percentage of patients aged 50 years and older who have had the Shingrix zoster (shingles) vaccination

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Oncology
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Preventive Medicine
    • Skilled Nursing Facility
    • *These measures represent the Nephrology 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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