Beginning with the 2023 Performance Period
Report 4 quality measures (one must be an outcome or a high priority measure):
- #111: Pneumococcal Vaccination Status for Older Adults (Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #130: Documentation of Current Medications in the Medical record (Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications) (!)
- #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs
- #176: Tuberculosis Screening Prior to First Course Biologic of improvements in patient portal Therapy (Medium) (MIPS CQMs Specifications)
- #177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity (MIPS CQMs Specifications)
- #178: Rheumatoid Arthritis (RA): Functional Status Assessment (MIPS CQMs Specifications)
- #180: Rheumatoid Arthritis (RA): Glucocorticoid Management (MIPS CQMs Specifications)
- ACR12: Disease Activity Measurements for Patients with PsA Patient's Medical Record (QCDR)
- ACR14: Gout Serum Urate Target (QCDR) (!)
- ACR15: Safe Hydroxychloroquine Dosing (QCDR) (!!)
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- IA_AHE_3: Promote use of Patient-Reported Outcome Tools (High)
- IA_BE_1: Use of certified EHR to capture patient reported outcomes (Medium)
- IA_BE_4: Engagement of patients through implementation
- IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care (Medium)
- IA_BMH_2: Tobacco use (Medium)
- IA_BMH_4: Depression screening (Medium)
- 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_EPA_2: Use of telehealth services that expand practice access (Medium)
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_16: Implementation of medication management practice improvements (Medium)
- IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program Medium
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 System (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 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
- 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).
- 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.