Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- #039: Screening for Osteoporosis for Women Aged 65-85 Years of Age (Collection Type: Medicare Part B Claims Measure Specifications, MIPS CQMs Specifications)
- #112: Breast Cancer Screening (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #113: Colorectal Cancer Screening (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications)
- #309: Cervical Cancer Screening (Collection Type: eCQM Specifications)
- #310: Chlamydia Screening for Women (Collection Type: eCQM Specifications)
- #321: CAHPS for MIPS Clinician/Group Survey (Collection Type: CAHPS Survey Vendor) (!)
- #400: One-Time Screening for Hepatitis C Virus (HCV) for all Patients (Collection Type: MIPS CQMs Specifications)
- #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (Collection Type: MIPS CQMs Specifications)
- #475: HIV Screening (Collection Type: eCQM Specifications)
- #483: Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) (Collection Type: MIPS CQMs Specifications) (!!)
- #493: Adult Immunization Status (Collection Type: 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
- 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_BMH_9: Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients (High)
- 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_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: Electronic submission of Patient Centered Medical Home accreditation
- IA_PM_11: Regular review practices in place on targeted patient population needs (Medium)
- IA_PM_13: Chronic Care and Preventative Care Management for Empaneled Patients (Medium)
- IA_PM_16: Implementation of medication management practice improvements (Medium)
- IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement 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.