Reference
MIPS quality measures
82 entries.
Entries
82
Controlling High Blood Pressure
Adults 18-85 with HTN whose most recent BP was <140/90 during the measurement period
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Adults 18-75 with diabetes whose A1c was >9% during measurement period — LOWER is better
Colorectal Cancer Screening
Adults 45-75 with appropriate screening completed
Breast Cancer Screening
Women 50-74 screened within 27 months
Preventive Care: Influenza Immunization
Patients ≥6 months who received flu vaccine in measurement period
Pneumococcal Vaccination Status for Older Adults
Adults ≥65 who ever received pneumococcal vaccine
Avoidance of Antibiotic Treatment for Acute Bronchitis (URI)
Patients with acute bronchitis NOT given antibiotic — HIGHER is better
Diabetes: Eye Exam
Diabetic patients with annual eye exam
Diabetes: Medical Attention for Nephropathy
Diabetic patients with annual nephropathy screening
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
Adults with BMI documented and follow-up if BMI outside range
Documentation of Current Medications in the Medical Record
Each visit has documented medication reconciliation
Preventive Care: Screening for Depression and Follow-Up Plan
Adults screened with validated tool + follow-up if positive
Preventive Care: Tobacco Use: Screening and Cessation Intervention
Adults screened for tobacco use + cessation intervention if positive
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patients 3-17 with BMI percentile + nutrition + activity counseling
Dementia: Cognitive Assessment
Dementia patients with annual cognitive assessment
Dementia: Functional Status Assessment
Dementia patients with annual functional status assessment
Maternal Depression Screening
Mothers screened for depression at well-child visits 0-6 months
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Patients with ASCVD or LDL ≥190 on statin
Depression Remission at Twelve Months
PHQ-9 ≥10 patients who achieved remission at 12 months
Closing the Referral Loop
Referring provider received completed consultation report
Care Plan
Patients 65+ with advance care plan documented
Continuity of Pharmacotherapy for Opioid Use Disorder
MOUD patients with continuous medication for ≥180 days
Preventive Care: Tobacco Use Screening and Cessation Intervention
Patients screened for tobacco use AND cessation intervention provided if positive
Fluoride Varnish for Children
Children 0-20 with fluoride varnish during measurement period
Preventive Care and Screening: BMI Screening and Follow-Up
Adults ≥18 with BMI documented + follow-up if outside normal range
Initiation and Engagement of Substance Use Disorder Treatment
Patients with new SUD diagnosis who initiated AND engaged in treatment
Engagement of SUD Treatment
Patients engaged ≥2 follow-up visits within 30 days of initiation
CAHPS for MIPS Survey
Patient experience survey responses
Osteoporosis Management in Women With a Fracture
Women 50-85 with osteoporosis-related fracture who received DXA or bisphosphonate
Statin Therapy for the Prevention and Treatment of CVD
Adults ≥21 with ASCVD on appropriate-intensity statin
Preventive Care: Unhealthy Alcohol Use - Screening and Brief Counseling
Adults screened with AUDIT-C or similar + brief counseling if positive
Depression Remission at Twelve Months
Adults with MDD or dysthymia with PHQ-9 <5 at 12 months
Medication Reconciliation Post-Discharge
Patient discharge with med rec completed within 30 days
Rheumatoid Arthritis: Functional Status Assessment
RA patients with documented functional status assessment
Rheumatoid Arthritis: TB Screening
RA patients on biologic with TB screening documented
Functional Outcome Assessment
Patients with chronic back/neck pain w/ outcomes tool (Oswestry, NDI)
Falls: Risk Assessment
Adults ≥65 screened for fall risk
Falls: Plan of Care
Adults ≥65 at fall risk with documented plan of care
Parkinson Disease: Comprehensive Annual Visit
PD patients with annual comprehensive plan documented
Preventive Care: Tobacco/Alcohol/Drug Use Screening Comprehensive
All adults screened for tobacco, alcohol, drug use
Functional Status After Rotator Cuff Repair
Functional improvement (DASH, ASES) at 1 year
Functional Status After Lumbar Discectomy
Functional improvement (ODI) at 1 year
Functional Status After Lumbar Fusion
ODI improvement at 1 year
Functional Status After Knee Arthroplasty
KOOS, WOMAC improvement at 1 year
Functional Status After Hip Arthroplasty
HOOS, WOMAC improvement at 1 year
Urinary Incontinence Assessment in Women
Women ≥65 assessed for urinary incontinence
COPD: Spirometry Evaluation
COPD diagnosis confirmed by spirometry
COPD: Long-Acting Inhaled Bronchodilator Therapy
COPD patients on LABA/LAMA where indicated
Appropriate Treatment for Children With URI
Children with URI NOT given antibiotic — HIGHER is better
Appropriate Testing for Pharyngitis
Strep test done before antibiotic
Acute Otitis Externa: Topical Therapy
AOE treated with topical instead of systemic abx
AOE: Pain Assessment
Pain assessed at AOE visit
Immunizations for Children
Children 2 with all recommended vaccines by 2nd birthday
Epilepsy: Documentation of Seizure Frequency
Seizure type + frequency documented
OME: Avoidance of Systemic Antibiotics (Inverse)
OME patients NOT given systemic abx — HIGHER better
Biopsy Follow-Up
Patients with biopsy notified of results
Ultrasound Determination of Pregnancy Location
First-trimester ultrasound to determine pregnancy location
Maternity Care: Postpartum Follow-Up Care
Postpartum visit 4-12 weeks
Unplanned Reoperation Within 30 Days
Surgical reoperation within 30 days
Surgical Site Infection (Inverse)
SSI rate post-surgery — LOWER better
Cataracts: 30-Day Postoperative Complication Rate
Severe complications within 30 days of cataract surgery — LOWER better
Cataracts: Improvement in Visual Function Within 90 Days
Postop visual function improvement to 20/40 or better
HIV/AIDS: Medical Visits
HIV+ patients with ≥2 visits ≥90 days apart
HIV/AIDS: PCP Prophylaxis
HIV+ with CD4 <200 on PCP prophylaxis
Cancer Screening Comprehensive (Composite)
Composite of breast, cervical, colorectal screening
Adherence to Antipsychotic Medications for Schizophrenia
Schizophrenia patients with PDC ≥80% for antipsychotic
Controlling High BP (2024 Update)
Adults 18-85 HTN with BP <140/90
Adult Major Depression: Suicide Risk Assessment
MDD patients assessed for suicide risk at each visit
Tobacco Cessation Pharmacotherapy
Tobacco users counseled on pharm options (NRT, varenicline, bupropion)
One-Time Screening for Hepatitis C (HCV) in Adults
Adults 18-79 with ≥1 HCV antibody test
Flu Vaccination (2024 update)
≥6 months received flu vaccine current season
Adult Sinusitis: Appropriate Antibiotic Treatment
Sinusitis with appropriate antibiotic OR no antibiotic per criteria
Adult Sinusitis: Computerized Tomography (CT) Imaging (Inverse)
Sinusitis NOT having CT in first 28 days — HIGHER better
Pleural Fluid Analysis
Pleural effusion with appropriate fluid analysis
Dementia: Caregiver Education and Support
Dementia patients/caregivers offered education
Dementia: Cognitive Assessment
Annual cognitive assessment for dementia patients
Dementia: Functional Status Assessment
Annual functional assessment
Dementia: Safety Concern Counseling
Dementia patients counseled re: safety (driving, wandering)
Stage III-IV Pressure Ulcer: Care Plan
Pressure ulcer with documented care plan
Anesthesiology Smoking Abstinence
Surgical patients counseled re: pre-op smoking cessation
Adult Immunization Status
Adult flu, Tdap, Zoster, pneumococcal status documented
Connection to Community Services for Elderly
Elderly patients with social risk connected to services
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