- 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:012NQF:0086eMeasure ID:CMS143v9High Priority:No
2021 MIPS Measure #012: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.
Measure Type- Process
SpecificationsSpecialty- Ophthalmology
ID:014NQF:0087eMeasure ID:High Priority:No2021 MIPS Measure #014: Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.
Measure Type- Process
SpecificationsSpecialty- Ophthalmology
ID:019NQF:0089eMeasure ID:CMS142v9High Priority:Yes2021 MIPS Measure #019: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months
Measure Type- Process
Specialty- Ophthalmology
ID:117NQF:0055eMeasure ID:CMS131v9High Priority:No2021 MIPS Measure #117: Diabetes: Eye Exam
Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period
Measure Type- Process
Specialty- Endocrinology
- Family Medicine
- Internal Medicine
- Ophthalmology
ID:130NQF:0419eeMeasure ID:CMS68v10High Priority:Yes2021 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
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/Hematology
- 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:141NQF:0563eMeasure ID:High Priority:Yes2021 MIPS Measure #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period
Measure Type- Outcome
SpecificationsSpecialty- Ophthalmology
ID:191NQF:0565eMeasure ID:CMS133v9High Priority:Yes2021 MIPS Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery
Measure Type- Outcome
Specialty- Ophthalmology
ID:226NQF:0028eMeasure ID:CMS138v9High Priority:No2021 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
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/Hematology
- 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:238NQF:0022eMeasure ID:CMS156v9High Priority:Yes2021 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
Specialty- Allergy/Immunology
- Cardiology
- Family Medicine
- Geriatrics
- Internal Medicine
- Ophthalmology
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
ID:303NQF:1536eMeasure ID:High Priority:Yes2021 MIPS Measure #303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey
Measure Type- Outcome
SpecificationsSpecialty- Ophthalmology
ID:304NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey
Measure Type- Outcome
SpecificationsSpecialty- Ophthalmology
ID:374NQF:eMeasure ID:CMS50v9High Priority:Yes2021 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
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Interventional Radiology
- Mental/Behavioral Health
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:384NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery
Measure Type- Outcome
SpecificationsSpecialty- Ophthalmology
ID:385NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye
Measure Type- Outcome
SpecificationsSpecialty- Ophthalmology
ID:389NQF:eMeasure ID:High Priority:Yes2021 MIPS Measure #389: Cataract Surgery: Difference Between Planned and Final Refraction
Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction
Measure Type- Outcome
SpecificationsSpecialty- Ophthalmology
- 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.
- e-Prescribing
- Query of Prescription Drug Monitoring Program (PDMP) (optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops by Sending Health Information
- Support Electronic Referral Loops by Receiving and Incorporating Health Information
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- 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:
- IA_EPA_1 - Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record (high weighted).
- IA_AHE_7-Comprehensive Eye Exams (medium weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_1 - Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).
- IA_BE_4 - Engagement of patients through implementation of improvements in patient portal (medium weighted).
- IA_BE_1 - Use of certified EHR to capture patient reported outcomes (medium weighted).
- IA_BE_3 - Engagement with QIN-QIO to implement self-management training programs (medium weighted).
- IA_BE_6 - Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (high weighted).
- IA_BE_15 - Engagement of Patients, Family, and Caregivers in Developing a Plan of Care (medium weighted).
- IA_BE_17 - Use of tools to assist patient self-management (medium weighted).
- IA_BE_22 - Improved Practices that Engage Patients Pre-Visit (medium weighted).
- IA_BE_25 - Drug Cost Transparency (high weighted).
- IA_ERP_2-Participation in a 60-day or greater effort to support domestic or international humanitarian needs (high weighted).
- IA_PM_6-Use of toolsets or other resources to close healthcare disparities across communities (medium weighted).
- IA_PSPA_2-Participation in MOC Part IV (medium weighted).
- IA_PSPA_8-Use of Patient Safety Tools (medium weighted).
- IA_PSPA_16 - Use of decision support and standardized treatment protocols (medium weighted).