Beginning with the 2023 Performance Period
Report 4 quality measures (one must be an outcome or a high priority measure):
- #005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (L VSD) (eCQM Specifications, MIPS CQMs Specifications)
- #007: Coronary Artery Disease (CAD): Beta-Blocker therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (L VEF < 40%) (eCQM Specifications, MIPS CQMs Specifications)
- #008: Heart Failure (HF): Beta-Blocker Therapy for Left t Transparency Ventricular Systolic Dysfunction (L VSD) (eCQM Specifications, MIPS CQMs Specifications)
- #047: Advance Care Plan (Medicare Part B Claims Measure Specifications, MIPS CQMs Specifications) (!)
- #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #238: Use of High-Risk Medications in Older Adults (eCQM Specifications, MIPS CQMs Specifications)
- #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting (MIPS CQMs Specifications)
- #441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) (MIPS CQMs Specifications) (!!)
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_BE_12: Use evidence-based decision aids to support shared decision-making (Medium)
- IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care (Medium)
- IA_BE_24: Financial Navigation Program (Medium)
- IA_BE_25: Drug Cost Transparency (High)
- IA_CC_9: Implementation of practices/processes for developing regular individual care plans (Medium)
- IA_CC_14: Practice improvements that engage community resources to support patient health goals (High)
- IA_EPA_4: Additional improvements in access as a result ofQIN/QIO TA (Medium)
- IA_PM_14: Implementation of methodologies for improvements in longitudinal care management for high risk patients (Medium)
- IA_PSPA_4: Administration of the AHRQ Survey of Patient Safety Culture (Medium)
- IA_PSPA_7: Use ofQCDR data for ongoing practice assessment and improvements (Medium)
- IA_PSPA_30: PCI Bleeding Campaign (High)
Calculated by CMS using administrative claims data:
- Elective Outpatient Percutaneous Coronary Intervention (PCI)
- ST Elevation Myocardial Infarction (STEMI) with PCI
- 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) (!!)
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.