Beginning with the 2023 Performance Period
Report 4 quality measures (one must be an outcome or a high priority measure):
- #001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications) (!!)
- #047: Advance Care Plan (Collection Type: Medicare Part B Claims Measure Specifications, MIPS CQMs Specifications) (!)
- #110: Preventive Care and Screening: Influenza Immunization (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #111: Pneumococcal Vaccination Status for Older Adults (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #130: Documentation of Current Medications in the Medical Record (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications) (!)
- #236: Controlling High Blood Pressure (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications) (!!)
- #482: Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate (Collection Type: MIPS CQMs Specifications) (!!)
- #489: Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy (Collection Type: MIPS CQMs Specifications)
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_4: Engagement of patients through implementation
- IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings (High)
- IA_BE_14: Engage Patients and Families to Guide Improvement in the System of Care (High)
- IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care (Medium)
- IA_BE_16: Promote Self-management in Usual Care (Medium)
- IA_CC_2: Implementation of improvements that contribute to more timely communication of test results (Medium)
- IA_CC_13: Practice improvements for bilateral exchange of patient information (Medium)
- IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_11: Regular review practices in place on targeted patient population needs (Medium)
- IA_PM_14: Implementation of methodologies for improvements in longitudinal care management for high risk patients (Medium)
- IA_PM_16: Implementation of medication management practice improvements (Medium)
- IA_PSPA_16: Use of decision support and standardized treatment protocols (Medium)
Calculated by CMS using administrative claims data:
- Total Per Capita Cost (TPCC)
- Acute Kidney Injury Requiring New Inpatient Dialysis (AKI)
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 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.