Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP

Beginning with the 2023 Performance Period


Report 4 quality measures (one must be an outcome or a high priority measure):

Improvement Activities

Report Two medium-weighted improvement activities or One high- weighted improvement activity:


Calculated by CMS using administrative claims data:

  • Medicare Spending Per Beneficiary (MSPB) Clinician

Population Health Measures

Select one population health measure to be scored by CMS using administrative claims data:

  • #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
  • #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)

Promoting Interoperability

Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:

  • Prevention of Information Blocking
  • e-Prescribing
  • Query of the Prescription Drug Monitoring Program (POMP) (Optional)
  • Provide Patients Electronic Access to Their Health Information
  • Support Electronic Referral Loops By Sending Health Information
  • Support Electronic Referral Loops By Receiving and Reconciling Health Information
  • Health Information Exchange (HIE) Bi-Directional Exchange
  • Immunization Registry Reporting
  • Syndromic Surveillance Reporting
  • Electronic Case Reporting
  • Public Health Registry Reporting
  • Clinical Data Registry Reporting
  • Security Risk Analysis
  • Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)


  • Quality measures that are considered high priority are identified with an exclamation point (!)
  • Outcome measures are identified with a double exclamation point (!!)

MVP Registration

  • MVP Participants must register between April 1 – November 30, 2023 to report an MVP in 2023.
  • To register, MVP Participants must select:
    • The MVP they intend to report.
    • 1 population health measure included in the MVP.
    • Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
  • MVP Participants won’t be able to:
    • Submit/make changes to the MVP they select after the close of the registration period (November 30, 2023).
    • Report on an MVP they didn’t register for during the 2023 performance year.
    • Report on more than one MVP.

Register with MDinteractive