Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- #024: Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older (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)
- #350: Total Knee or Hip Replacement: Shared Decision-making: Trial of Conservative (Non-surgical) Therapy (MIPS CQMs Specifications) (!)
- #351: Total Knee or Hip Replacement: Venous thromboembolic and Cardiovascular Risk Evaluation (MIPS CQMs Specifications) (!)
- #376: Functional Status Assessment for Total Hip replacement (eCQM Specifications) (!)
- #470: Functional Status After Primary Total Knee replacement (MIPS CQMs Specifications) (!!)
- #480: Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (Administrative Claims) (!!)
Improvement Activities
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_6: Regularly Assess Patient Experience of Care and Follow Up on Findings (High)
- IA_BE_12: Use evidence-based decision aids to support shared decision-making (Medium)
- IA_CC_7: Regular training in care coordination (Medium)
- IA_CC_9: Implementation of practices/processes for developing regular individual care plans (Medium)
- IA_CC_13: Practice improvements for bilateral exchange of patient information (Medium)
- IA_CC_15: PSH Care Coordination (High)
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PSPA_7: Use ofQCDR data for ongoing practice assessment and improvements (Medium)
- IA_PSPA_18: Measurement and improvement at the practice and panel level (Medium)
- IA_PSPA_27: Invasive Procedure or Surgery Anticoagulation Medication Management (Medium)
Cost
Calculated by CMS using administrative claims data:
- Elective Primary Hip Arthroplasty
- Knee Arthroplasty
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.