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MIPS Measures Relevant to Neurology

  1. Quality - 45% 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:
    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:
    134
    NQF:
    0418
    eMeasure ID:
    CMS2v10
    High Priority:
    No

    2021 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
    Specifications
    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:
    154
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #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
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    155
    NQF:
    0101
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #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
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:
    181
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • 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:
    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:
    268
    NQF:
    1814
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

    Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    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:
    281
    NQF:
    2872e
    eMeasure ID:
    CMS149v9
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    282
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:
    283
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    286
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    288
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 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
    Specifications
    Specialty
    • Clinical Social Work
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    • Physical Therapy/Occupational Therapy
    ID:
    290
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease

    Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms once in the past 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:
    291
    NQF:
    eMeasure ID:
    High Priority:
    No

    2021 MIPS Measure #291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease

    Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once in the past 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:
    293
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #293: Parkinson’s Disease: Rehabilitative Therapy Options

    Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed once in the past 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:
    317
    NQF:
    eMeasure ID:
    CMS22v9
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Plastic Surgery
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    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:
    386
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

    Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:
    402
    NQF:
    2803
    eMeasure ID:
    High Priority:
    No

    2021 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
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urgent Care
    • Vascular Surgery
    ID:
    419
    NQF:
    eMeasure ID:
    High Priority:
    Yes

    2021 MIPS Measure #419: Overuse of Imaging for the Evaluation of Primary Headache

    Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    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
    • *These  measures make up the Neurology 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, 2020. There are exclusions available for most of the required measures. 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 making it 70% 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.  There are over 100 possible measures to choose from. The following are suggestions only:

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