Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- #006: Coronary Artery Disease (CAD): Antiplatelet therapy MIPS CQMs Specifications)
- #047: Advance Care Plan Medicare Part B Claims, MIPS CQMs Specifications) (!)
- #107: Adult Major Depressive Disorder (MDD): Suicide risk Assessment (eCQM Specifications)
- #118: Coronary Artery Disease (CAD): Angiotensin-converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (L VEF < 40%) MIPS CQMs Specifications)
- #236: Controlling High Blood Pressure ( Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications) (!!)
- #321: CAHPS for MIPS Clinician/Group Survey(Collection Type: CAHPS Survey Vendor) (!)
- #398: Optimal Asthma Control (MIPS CQMs Specifications) (!!)
- #438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (eCQM Specifications, MIPS CQMs Specifications)
- #483: Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure PCPCM PRO-PM) MIPS CQMs Specifications) (!!)
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_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
- IA_BE_4: Engagement of patients through implementation of improvements in patient portal (Medium)
- IA_BE_16: Promote Self-management in Usual Care (Medium)
- IA_BE_22: Improved practices that engage patients pre-visit (Medium)
- IA_CC_2: Implementation of improvements that contribute to more timely communication of test results (Medium)
- IA_CC_12: Care coordination agreements that promote improvements in patient tracking across settings (Medium)
- IA_CC_13: Practice improvements for bilateral exchange of patient information (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_PCMH: Implementation of Patient-Centered Medical home model
- IA_PM_13: Chronic care and preventative care management for empaneled patients (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 ractice assessment and improvements (Medium)
- IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvements processes (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.