- 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:024NQF:0045eMeasure ID:High Priority:Yes
2021 MIPS Measure #024: Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication
Measure Type- Process
SpecificationsSpecialty- Family Medicine
- Internal Medicine
- Orthopedic Surgery
- Preventive Medicine
- Rheumatology
ID:039NQF:0046eMeasure ID:High Priority:No2021 MIPS Measure #039: Screening for Osteoporosis for Women Aged 65-85 Years of Age
Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis
Measure Type- Process
SpecificationsSpecialty- Endocrinology
- Family Medicine
- Geriatrics
- Internal Medicine
- Preventive Medicine
- Rheumatology
ID:047NQF:0326eMeasure ID:High Priority:Yes2021 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
SpecificationsSpecialty- Cardiology
- Clinical Social Work
- Family Medicine
- Gastroenterology
- General Surgery
- Geriatrics
- Hospitalists
- Internal Medicine
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
- Thoracic Surgery
- Urology
- Vascular Surgery
ID:110NQF:0041eMeasure ID:CMS147v10High Priority:No2021 MIPS Measure #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
Specialty- Allergy/Immunology
- Cardiology
- Endocrinology
- Family Medicine
- Geriatrics
- Infectious Disease
- Internal Medicine
- Nephrology
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Pediatrics
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
ID:111NQF:0043eMeasure ID:CMS127v9High Priority:No2021 MIPS Measure #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
Specialty- Allergy/Immunology
- Cardiology
- Endocrinology
- Family Medicine
- Geriatrics
- Infectious Disease
- Internal Medicine
- Obstetrics/Gynecology
- Oncology/Hematology
- Otolaryngology
- Preventive Medicine
- Pulmonology
- Rheumatology
- Skilled Nursing Facility
ID:128NQF:0421eMeasure ID:CMS69v9High Priority:No2021 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters
Measure Type- Process
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nutrition/Dietician
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Physical Therapy/Occupational Therapy
- Podiatry
- Preventive Medicine
- Pulmonology
- Rheumatology
- Urology
- Vascular Surgery
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:176NQF:eMeasure ID:High Priority:No2021 MIPS Measure #176: Rheumatoid Arthritis (RA): Tuberculosis Screening
If a patient has been newly prescribed a biologic disease-modifying anti-rheumatic drug (DMARD) therapy, then the medical record should indicate TB testing in the preceding 12-month period.
Measure Type- Process
SpecificationsSpecialty- Rheumatology
ID:177NQF:eMeasure ID:High Priority:No2021 MIPS Measure #177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the measurement year
Measure Type- Process
SpecificationsSpecialty- Rheumatology
ID:178NQF:eMeasure ID:High Priority:No2021 MIPS Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months
Measure Type- Process
SpecificationsSpecialty- Orthopedic Surgery
- Rheumatology
ID:180NQF:eMeasure ID:High Priority:No2021 MIPS Measure #180: Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months
Measure Type- Process
SpecificationsSpecialty- Orthopedic Surgery
- Rheumatology
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:236NQF:0018eMeasure ID:CMS165v9High Priority:Yes2021 MIPS Measure #236: Controlling High Blood Pressure
Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period
Measure Type- Intermediate Outcome
Specialty- Cardiology
- Endocrinology
- Family Medicine
- Internal Medicine
- Obstetrics/Gynecology
- Pulmonology
- Rheumatology
- 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:317NQF:eMeasure ID:CMS22v9High Priority:No2021 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
Specialty- Allergy/Immunology
- Cardiology
- Dermatology
- Emergency Medicine
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Nephrology
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Plastic Surgery
- Preventive Medicine
- Rheumatology
- Skilled Nursing Facility
- Thoracic Surgery
- Urgent Care
- Urology
- Vascular Surgery
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:402NQF:2803eMeasure ID:High Priority:No2021 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
SpecificationsSpecialty- Allergy/Immunology
- Cardiology
- Clinical Social Work
- Dermatology
- Family Medicine
- Gastroenterology
- General Surgery
- Internal Medicine
- Mental/Behavioral Health
- Neurology
- Obstetrics/Gynecology
- Oncology/Hematology
- Orthopedic Surgery
- Otolaryngology
- Pediatrics
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urgent Care
- Vascular Surgery
- 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_3 - Collection and use of patient experience and satisfaction data on access (medium weighted).
- IA_AHE_1 - Engagement of new Medicaid patients and follow-up (high weighted).
- IA_BE_14 - Engage patients and families to guide improvement in the system of care (high weighted).
- IA_CC_8 - Implementation of documentation improvements for practice/process improvements (medium weighted).
- IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results (medium weighted).