MIPS Measures Relevant to Neurology

  1. Quality - 45% of total score:  Report 6 measures, including one Outcome or one 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:

    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:

    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:

    134
    NQF:

    0418
    eMeasure ID:

    CMS2v7
    High Priority:

    No

    #134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

    Percentage of patients aged 12 years and older screened for depression on 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 positive screen

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Orthopedic Surgery
    • Pediatrics
    • Preventive Medicine
    ID:

    154
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #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
    • Family Medicine
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    155
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #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
    • Family Medicine
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    181
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Skilled Nursing Facility
    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:

    268
    NQF:

    1814
    eMeasure ID:
    High Priority:

    No

    #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

    All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:

    281
    NQF:

    2872
    eMeasure ID:

    CMS149v6
    High Priority:

    No

    #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
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    282
    NQF:
    eMeasure ID:
    High Priority:

    No

    #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
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    283
    NQF:
    eMeasure ID:
    High Priority:

    No

    #283: Dementia: Neuropsychiatric Symptom Assessment

    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
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    286
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #286: Dementia: Counseling Regarding Safety Concerns

    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
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    288
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #288: Dementia: Caregiver Education and Support

    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
    • Geriatrics
    • Mental/Behavioral Health
    • Neurology
    ID:

    290
    NQF:
    eMeasure ID:
    High Priority:

    No

    #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 in the past 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:

    291
    NQF:
    eMeasure ID:
    High Priority:

    No

    #291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    ID:

    293
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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 in the past 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Neurology
    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:

    374
    NQF:
    eMeasure ID:

    CMS50v6
    High Priority:

    Yes

    #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
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    386
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #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:
    eMeasure ID:
    High Priority:

    No

    #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
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urgent Care
    • Vascular Surgery
    ID:

    408
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #408: Opioid Therapy Follow-up Evaluation

    All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    412
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #412: Documentation of Signed Opioid Treatment Agreement

    All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    414
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #414: Evaluation or Interview for Risk of Opioid Misuse

    All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    419
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #419: Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination

    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

    #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 24 months AND who received brief counseling if identified as an unhealthy alcohol user

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • Oncology
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Urgent Care
    • Urology
    ID:

    435
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #435: Quality of Life Assessment For Patients With Primary Headache Disorders

    Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurology
    • *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, 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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