MIPS Measures Relevant to Radiologists

  1. Quality - 70% 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:

    145
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #145: Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy

    Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    • Interventional Radiology
    ID:

    146
    NQF:

    0508
    eMeasure ID:
    High Priority:

    Yes

    #146: Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms

    Percentage of final reports for screening mammograms that are classified as “probably benign”

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    147
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #147: Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

    Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    195
    NQF:

    0507
    eMeasure ID:
    High Priority:

    No

    #195: Radiology: Stenosis Measurement in Carotid Imaging Reports

    Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    225
    NQF:

    0509
    eMeasure ID:
    High Priority:

    Yes

    #225: Radiology: Reminder System for Screening Mammograms

    Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram

    Measure Type
    • Structure
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    360
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

    Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    361
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #361: Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry

    Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements

    Measure Type
    • Structure
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    362
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #362: Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes

    Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12 month period after the study

    Measure Type
    • Structure
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    364
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

    Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians)

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    405
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions

    Percentage of final reports for abdominal imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended

    • Liver lesion ≤ 0.5 cm
    • Cystic kidney lesion < 1.0 cm
    • Adrenal lesion ≤ 1.0 cm

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    406
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

    Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    ID:

    436
    NQF:
    eMeasure ID:
    High Priority:

    No

    #436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

    Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used
    • Automated exposure control
    • Adjustment of the mA and/or kV according to patient size
    • Use of iterative reconstruction technique

    Measure Type
    • Process
    Specifications
    Specialty
    • Diagnostic Radiology
    • *These  registry measures make-up the Diagnostic Radiology Measures Set
  2. 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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