Beginning with the 2023 Performance Period
Report 4 quality measures (one must be an outcome or a high priority measure):
- #116: Avoidance of Antibiotic Treatment for Acute bronchitis/Bronchiolitis (MIPS CQMs Specifications)
- #254: ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain (MIPS CQMs Specifications)
- #321: CAHPS for MIPS Clinician/Group survey (CAHPS Survey Vendor) (!)
- #331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) (MIPS CQMs Specifications) (!)
- #415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older (MIPS CQMs Specifications)
- ACEP21: Coagulation studies in patients presenting with chest pain with no coagulopathy or bleeding (QCDR) (!)
- ACEP50: ED Median Time from ED Arrival to ED departure for all adult Patients (QCDR) (!!)
- ACEP52: Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain (QCDR) (!)
- ECPR46: Avoidance of Opiates for Low Back Pain or Migraines (QCDR) (!)
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_BE_4: Engagement of patients through implementation of improvements in patient portal (Medium)
- IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings (High)
- IA_CC_2: Implementation of improvements that contribute to more timely communication of test results (Medium)
- IA_CC_14: Practice improvements that engage community resources to support patient health goals (High)
- IA_PSPA_1: Participation in an AHRQ-listed patient safety organization(Medium)
- IA_PSPA_6: Consultation of the Prescription Drug Monitoring Program (High)
- IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements (Medium)
- IA_PSPA_15: Implementation of Antimicrobial Stewardship Program (ASP) (Medium)
- IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvement processes (Medium)
- IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes (Medium)
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) (!!)
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Prevention of Information Blocking
- 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 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.