MIPS Measures Relevant to Oncology & Hematology

  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:

    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:

    102
    NQF:

    0389
    eMeasure ID:

    CMS129v7
    High Priority:

    Yes

    #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

    Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    • Radiation Oncology
    • Urology
    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:

    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:

    143
    NQF:

    0384
    eMeasure ID:

    CMS157v6
    High Priority:

    Yes

    #143: Oncology: Medical and Radiation – Pain Intensity Quantified

    Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    • Radiation Oncology
    ID:

    144
    NQF:

    0383
    eMeasure ID:
    High Priority:

    Yes

    #144: Oncology: Medical and Radiation – Plan of Care for Pain

    Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    • Radiation Oncology
    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:

    250
    NQF:

    1853
    eMeasure ID:
    High Priority:

    No

    #250: Radical Prostatectomy Pathology Reporting

    Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    • Pathology
    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:

    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:

    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:

    449
    NQF:

    1857
    eMeasure ID:
    High Priority:

    Yes

    #449: HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies

    Percentage of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    ID:

    450
    NQF:

    1858
    eMeasure ID:
    High Priority:

    Yes

    #450: Trastuzumab Received By Patients With AJCC Stage I (T1c)–III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy

    Percentage of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving Trastuzumab

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    ID:

    451
    NQF:

    1859
    eMeasure ID:
    High Priority:

    No

    #451: KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy

    Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    ID:

    452
    NQF:

    1860
    eMeasure ID:
    High Priority:

    Yes

    #452: Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies

    Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    ID:

    453
    NQF:

    0210
    eMeasure ID:
    High Priority:

    Yes

    #453: Proportion Receiving Chemotherapy in the Last 14 Days of Life

    Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    ID:

    454
    NQF:

    0211
    eMeasure ID:
    High Priority:

    Yes

    #454: Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life

    Percentage of patients who died from cancer with more than one emergency department visit in the last 30 days of life

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Oncology
    ID:

    455
    NQF:

    0213
    eMeasure ID:
    High Priority:

    Yes

    #455: Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life

    Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Oncology
    • Geriatrics
    ID:

    456
    NQF:

    0215
    eMeasure ID:
    High Priority:

    Yes

    #456: Proportion Not Admitted To Hospice

    Percentage of patients who died from cancer not admitted to hospice

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    ID:

    457
    NQF:

    0216
    eMeasure ID:
    High Priority:

    Yes

    #457: Proportion Admitted to Hospice for less than 3 days

    Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Oncology
    ID:

    462
    NQF:
    eMeasure ID:

    CMS645v1
    High Priority:

    No

    #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

    Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater (indicated by HCPCS code) and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

    Measure Type
    • Process
    Specifications
    Specialty
    • Oncology
    • Urology
    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 registry measures (plus EHR only measure 462) make-up the Oncology 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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