Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- #047: Advance Care Plan (Collection Type: Medicare Part B Claims Measure Specifications, MIPS CQMs Specifications) (!)
- #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #143: Oncology: Medical and Radiation – Pain Intensity Quantified (Collection Type: eCQM Specifications, MIPS CQMs Specifications) (!)
- #144: Oncology: Medical and Radiation – Plan of Care for Pain (Collection Type: MIPS CQMs Specifications) (!)
- #321: CAHPS for MIPS Clinician/Group Survey (Collection Type: CAHPS Survey Vendor) (!)
- #450: Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer (Collection Type: MIPS CQMs Specifications) (!)
- #451: RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy (Collection Type: MIPS CQMs Specifications)
- #452: Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies (Collection Type: MIPS CQMs Specifications) (!)
- #453: Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better) (Collection Type: MIPS CQMs Specifications) (!)
- #457: Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) (Collection Type: MIPS CQMs Specifications) (!!)
- #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (Collection Type: eCQM Specifications)
- PIMSH2: Oncology: Utilization of GCSF in Metastatic Colorectal Cancer (Collection Type: QCDR) (!)
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_BE_4: Engagement of patients through implementation
- IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings (High)
- IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care (Medium)
- IA_BE_24: Financial Navigation Program (Medium)
- IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop (Medium)
- IA_CC_17: Patient Navigator Program (High)
- IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record (High)
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_14: Implementation of methodologies for improvements in longitudinal care management for high risk patients (Medium)
- IA_PM_15: Implementation of episodic care management practice improvements (Medium)
- IA_PM_16: Implementation of medication management practice improvements (Medium)
- IA_PM_21: Advance Care Planning (Medium)
- IA_PSPA_16: Use of Decision Support and Standardized Treatment Protocols (Medium)
Cost
Calculated by CMS using administrative claims data:
- Total Per Capita Cost (TPCC)
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 AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- 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)
- ONC Direct Review
Notes:
- 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).
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- 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.
- The 2023 MVP Registration Form can be found at this link.