From 2e4449ea6e4779a5e9d1cf7ab27e4ec0e27e76eb Mon Sep 17 00:00:00 2001 From: ckawell-sb <104456459+ckawell-sb@users.noreply.github.com> Date: Mon, 8 May 2023 11:34:24 -0500 Subject: [PATCH 1/2] feat: QPPA-7672 add pre prod pi measures --- measures/2023/measures-data.json | 190 ++++++++++++++++++ updates/measures/2023/PI_PY23_CR_20230504.csv | 16 ++ updates/measures/2023/changes.meta.json | 3 +- 3 files changed, 208 insertions(+), 1 deletion(-) create mode 100644 updates/measures/2023/PI_PY23_CR_20230504.csv diff --git a/measures/2023/measures-data.json b/measures/2023/measures-data.json index 4c268d37..cdfc65ce 100644 --- a/measures/2023/measures-data.json +++ b/measures/2023/measures-data.json @@ -2248,6 +2248,196 @@ "exclusion": null, "allowedPrograms": [] }, + { + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [] + }, { "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", "eMeasureId": "CMS122v11", diff --git a/updates/measures/2023/PI_PY23_CR_20230504.csv b/updates/measures/2023/PI_PY23_CR_20230504.csv new file mode 100644 index 00000000..417308c7 --- /dev/null +++ b/updates/measures/2023/PI_PY23_CR_20230504.csv @@ -0,0 +1,16 @@ +Category,Measure ID,Measure Title,Measure Description,Required,Metric Type,First Performance Year,Year Removed,Objective,Bonus,Reporting Category,Substitutes,Exclusions +Value: PI,Question for the team: wonder if this should be active level engagement ID,,,"Value: TRUE, FALSE","Value: boolean, proportion",,Enter current PY if measure is to be removed,"Value: Protect Patient Health Information, Public Health And Clinical Data Exchange, Provider to Patient Exchange, e-Prescribing, Health Information Exchange, NULL","Value: TRUE, FALSE","required, bonus, exclusion, NULL","** Comma delimited list ** + +If you need to remove ALL Substitutes, or for a new measure with no substitutes - enter NULL","** Comma delimited list ** + +If you need to remove ALL Exclusions, or for a new measure with no exclusions - enter NULL" +PI,PI_PHCDRR_1_PRE,Immunization Registry Reporting Active Engagement Level 1,"Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.",TRUE,boolean,2023,,Public Health And Clinical Data Exchange,FALSE,required ,PI_PHCDRR_1_PROD,NULL +PI,PI_PHCDRR_1_PROD,Immunization Registry Reporting Active Engagement Level 2,Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.,TRUE,boolean,2023,,Public Health And Clinical Data Exchange,FALSE,required ,PI_PHCDRR_1_PRE,NULL +PI,PI_PHCDRR_2_PRE,Syndromic Surveillance Reporting Active Engagement Level 1,"Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.",TRUE,boolean,2023,,Public Health And Clinical Data Exchange,TRUE,bonus,PI_PHCDRR_2_PROD,NULL +PI,PI_PHCDRR_2_PROD,Syndromic Surveillance Reporting Active Engagement Level 2,Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.,TRUE,boolean,2023,,Public Health And Clinical Data Exchange,TRUE,bonus,PI_PHCDRR_2_PRE,NULL +PI,PI_PHCDRR_3_PRE,Electronic Case Reporting Active Engagement Level 1,"Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.",TRUE,boolean,2023,,Public Health And Clinical Data Exchange,FALSE,required ,PI_PHCDRR_3_PROD,NULL +PI,PI_PHCDRR_3_PROD,Electronic Case Reporting Active Engagement Level 2,Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.,TRUE,boolean,2023,,Public Health And Clinical Data Exchange,FALSE,required ,PI_PHCDRR_3_PRE,NULL +PI,PI_PHCDRR_4_PRE,Public Health Registry Reporting Active Engagement Level 1,"Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.",TRUE,boolean,2023,,Public Health And Clinical Data Exchange,TRUE,bonus,PI_PHCDRR_4_PROD,NULL +PI,PI_PHCDRR_4_PROD,Public Health Registry Reporting Active Engagement Level 2,Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.,TRUE,boolean,2023,,Public Health And Clinical Data Exchange,TRUE,bonus,PI_PHCDRR_4_PRE,NULL +PI,PI_PHCDRR_5_PRE,Clinical Data Registry Reporting Active Engagement Level 1,"Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.",TRUE,boolean,2023,,Public Health And Clinical Data Exchange,TRUE,bonus,PI_PHCDRR_5_PROD,NULL +PI,PI_PHCDRR_5_PROD,Clinical Data Registry Reporting Active Engagement Level 2,Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.,TRUE,boolean,2023,,Public Health And Clinical Data Exchange,TRUE,bonus,PI_PHCDRR_5_PRE,NULL \ No newline at end of file diff --git a/updates/measures/2023/changes.meta.json b/updates/measures/2023/changes.meta.json index 673c52c9..f5e607a0 100644 --- a/updates/measures/2023/changes.meta.json +++ b/updates/measures/2023/changes.meta.json @@ -22,5 +22,6 @@ "Quality_QCDR_PY23_CR_20230117.csv", "Quality_QCDR_PY23_CR_20230118.csv", "Qualtiy_QCDR_PY23_CR_20230130.csv", - "Quality_QCDR_PY23_20230216.csv" + "Quality_QCDR_PY23_20230216.csv", + "PI_PY23_CR_20230504.csv" ] \ No newline at end of file From 0b89d7959ec8930b2971b6aefb8c7ae5e4a7c46a Mon Sep 17 00:00:00 2001 From: ckawell-sb <104456459+ckawell-sb@users.noreply.github.com> Date: Mon, 8 May 2023 12:08:16 -0500 Subject: [PATCH 2/2] feat: QPPA-7672 add to all mvps --- measures/2023/measures-data.json | 150 +- mvp/2023/mvp-enriched.json | 11688 +++++++++++++++++++---------- mvp/2023/mvp.json | 144 +- 3 files changed, 8036 insertions(+), 3946 deletions(-) diff --git a/measures/2023/measures-data.json b/measures/2023/measures-data.json index cdfc65ce..c0664331 100644 --- a/measures/2023/measures-data.json +++ b/measures/2023/measures-data.json @@ -2265,7 +2265,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2284,7 +2297,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2303,7 +2329,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2322,7 +2361,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2341,7 +2393,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2360,7 +2425,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2379,7 +2457,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2398,7 +2489,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2417,7 +2521,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "category": "pi", @@ -2436,7 +2553,20 @@ ], "measureSets": [], "exclusion": null, - "allowedPrograms": [] + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", diff --git a/mvp/2023/mvp-enriched.json b/mvp/2023/mvp-enriched.json index 9605f557..e4013ce1 100644 --- a/mvp/2023/mvp-enriched.json +++ b/mvp/2023/mvp-enriched.json @@ -1208,34 +1208,25 @@ "M0003", "M0004" ] - } - ], - "foundationQualityMeasures": [ + }, { - "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "479", - "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2021, + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -1248,38 +1239,58 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" ], "measureSets": [], - "measureSpecification": {} + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "484", - "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2022, + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -1292,199 +1303,247 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], "measureSets": [], - "measureSpecification": {} - } - ], - "administrativeClaimsMeasures": [] - }, - { - "mvpId": "G0054", - "clinicalTopic": "Stroke Care and Prevention", - "title": "Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes", - "description": "The Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP focuses on the clinical theme of providing fundamental prevention and treatment of those patients at risk for or that have had a stroke.", - "specialtiesMostApplicableTo": [ - "Neurology", - "Neurosurgical", - "Vascular Surgery" - ], - "clinicalTopics": "Stroke Care and Prevention", - "allowedVendors": [], - "hasCahps": false, - "hasOutcomeAdminClaims": false, - "qualityMeasures": [ + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, { - "title": "Advance Care Plan", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "0326", - "measureId": "047", - "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", + "G0053", "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "claims", - "registry" - ], - "measureSets": [ - "cardiology", - "certifiedNurseMidwife", - "clinicalSocialWork", - "familyMedicine", - "gastroenterology", - "generalSurgery", - "geriatrics", - "hospitalists", - "internalMedicine", - "nephrology", - "neurology", - "obstetricsGynecology", - "oncology", - "orthopedicSurgery", - "otolaryngology", - "physicalMedicine", - "preventiveMedicine", - "pulmonology", - "rheumatology", - "skilledNursingFacility", - "thoracicSurgery", - "urology", - "vascularSurgery" - ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" - } + ] }, { - "title": "Stroke and Stroke Rehabilitation: Thrombolytic Therapy", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "187", - "description": "Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0054" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "cardiology", - "emergencyMedicine", - "neurosurgical" - ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_187_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Controlling High Blood Pressure", - "eMeasureId": "CMS165v11", - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "236", - "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", - "measureType": "intermediateOutcome", - "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", + "G0053", "G0054", + "G0055", "G0056", - "M0002" - ], - "submissionMethods": [ - "claims", - "electronicHealthRecord", - "cmsWebInterface", - "registry" + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" ], - "measureSets": [ - "cardiology", - "endocrinology", - "familyMedicine", - "internalMedicine", - "obstetricsGynecology", - "pulmonology", - "rheumatology", - "vascularSurgery" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + } + ], + "foundationQualityMeasures": [ + { + "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "measureId": "326", - "description": "Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "measureId": "479", + "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", + "measureType": "outcome", + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -1492,39 +1551,43 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", + "app1", + "G0053", "G0054", - "G0055" + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ - "registry" - ], - "measureSets": [ - "cardiology", - "familyMedicine", - "internalMedicine", - "skilledNursingFacility" + "administrativeClaims" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_326_MIPSCQM.pdf" - } + "measureSets": [], + "measureSpecification": {} }, { - "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", + "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "measureId": "344", - "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.", + "measureId": "484", + "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", "measureType": "outcome", "isHighPriority": true, - "primarySteward": "Society for Vascular Surgeons", - "firstPerformanceYear": 2017, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -1532,22 +1595,279 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", - "G0054" + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ - "registry" - ], - "measureSets": [ - "cardiology", - "neurosurgical", - "vascularSurgery" + "administrativeClaims" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_344_MIPSCQM.pdf" + "measureSets": [], + "measureSpecification": {} + } + ], + "administrativeClaimsMeasures": [] + }, + { + "mvpId": "G0054", + "clinicalTopic": "Stroke Care and Prevention", + "title": "Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes", + "description": "The Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes MVP focuses on the clinical theme of providing fundamental prevention and treatment of those patients at risk for or that have had a stroke.", + "specialtiesMostApplicableTo": [ + "Neurology", + "Neurosurgical", + "Vascular Surgery" + ], + "clinicalTopics": "Stroke Care and Prevention", + "allowedVendors": [], + "hasCahps": false, + "hasOutcomeAdminClaims": false, + "qualityMeasures": [ + { + "title": "Advance Care Plan", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0326", + "measureId": "047", + "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054", + "G0055", + "G0056", + "M0001", + "M0002", + "M0003", + "M0004" + ], + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "cardiology", + "certifiedNurseMidwife", + "clinicalSocialWork", + "familyMedicine", + "gastroenterology", + "generalSurgery", + "geriatrics", + "hospitalists", + "internalMedicine", + "nephrology", + "neurology", + "obstetricsGynecology", + "oncology", + "orthopedicSurgery", + "otolaryngology", + "physicalMedicine", + "preventiveMedicine", + "pulmonology", + "rheumatology", + "skilledNursingFacility", + "thoracicSurgery", + "urology", + "vascularSurgery" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" + } + }, + { + "title": "Stroke and Stroke Rehabilitation: Thrombolytic Therapy", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "187", + "description": "Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "cardiology", + "emergencyMedicine", + "neurosurgical" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_187_MIPSCQM.pdf" + } + }, + { + "title": "Controlling High Blood Pressure", + "eMeasureId": "CMS165v11", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "236", + "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "app1", + "G0054", + "G0056", + "M0002" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [ + "cardiology", + "endocrinology", + "familyMedicine", + "internalMedicine", + "obstetricsGynecology", + "pulmonology", + "rheumatology", + "vascularSurgery" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" + } + }, + { + "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "326", + "description": "Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054", + "G0055" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "cardiology", + "familyMedicine", + "internalMedicine", + "skilledNursingFacility" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_326_MIPSCQM.pdf" + } + }, + { + "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "344", + "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.", + "measureType": "outcome", + "isHighPriority": true, + "primarySteward": "Society for Vascular Surgeons", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "cardiology", + "neurosurgical", + "vascularSurgery" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_344_MIPSCQM.pdf" } }, { @@ -2462,34 +2782,25 @@ "M0003", "M0004" ] - } - ], - "foundationQualityMeasures": [ + }, { - "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "479", - "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2021, + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -2502,38 +2813,26 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} + ] }, { - "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "484", - "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2022, + "category": "pi", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -2546,168 +2845,279 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} - } - ], - "administrativeClaimsMeasures": [] - }, - { - "mvpId": "G0055", - "clinicalTopic": "Heart Disease", - "title": "Advancing Care for Heart Disease", - "description": "The Advancing Care for Heart Disease MVP focuses on the clinical theme of providing fundamental treatment and management of costly clinical conditions that contribute to, or may result from, heart disease.", - "specialtiesMostApplicableTo": [ - "Cardiology", - "Internal Medicine", - "Family Medicine" - ], - "clinicalTopics": "Heart Disease", - "allowedVendors": [], - "hasCahps": false, - "hasOutcomeAdminClaims": true, - "qualityMeasures": [ + ] + }, { - "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", - "eMeasureId": "CMS135v11", - "nqfEMeasureId": "0081e", - "nqfId": "0081", - "measureId": "005", - "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0055" - ], - "submissionMethods": [ - "electronicHealthRecord", - "registry" - ], - "measureSets": [ - "cardiology", - "familyMedicine", - "hospitalists", - "internalMedicine" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_005_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms135v11" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", - "eMeasureId": "CMS145v11", - "nqfEMeasureId": "0070e", - "nqfId": "0070", - "measureId": "007", - "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker therapy.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0055" - ], - "submissionMethods": [ - "electronicHealthRecord", - "registry" - ], - "measureSets": [ - "cardiology", - "familyMedicine", - "internalMedicine", - "skilledNursingFacility" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_007_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms145v11" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", - "eMeasureId": "CMS144v11", - "nqfEMeasureId": "0083e", - "nqfId": "0083", - "measureId": "008", - "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0055" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" ], - "submissionMethods": [ - "electronicHealthRecord", - "registry" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" ], - "measureSets": [ - "cardiology", - "familyMedicine", - "hospitalists", - "internalMedicine", - "skilledNursingFacility" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_008_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms144v11" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Advance Care Plan", + "category": "pi", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + } + ], + "foundationQualityMeasures": [ + { + "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": "0326", - "measureId": "047", - "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", - "measureType": "process", + "nqfId": null, + "measureId": "479", + "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", + "measureType": "outcome", "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -2715,65 +3125,43 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", + "app1", + "G0053", "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", "M0002", "M0003", "M0004" ], "submissionMethods": [ - "claims", - "registry" - ], - "measureSets": [ - "cardiology", - "certifiedNurseMidwife", - "clinicalSocialWork", - "familyMedicine", - "gastroenterology", - "generalSurgery", - "geriatrics", - "hospitalists", - "internalMedicine", - "nephrology", - "neurology", - "obstetricsGynecology", - "oncology", - "orthopedicSurgery", - "otolaryngology", - "physicalMedicine", - "preventiveMedicine", - "pulmonology", - "rheumatology", - "skilledNursingFacility", - "thoracicSurgery", - "urology", - "vascularSurgery" + "administrativeClaims" ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" - } + "measureSets": [], + "measureSpecification": {} }, { - "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", - "eMeasureId": "CMS69v11", + "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", + "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "measureId": "128", - "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.", - "measureType": "process", - "isHighPriority": false, + "measureId": "484", + "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", + "measureType": "outcome", + "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -2781,17 +3169,269 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", + "app1", + "G0053", + "G0054", "G0055", + "G0056", + "G0057", "G0058", - "M0005" + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ - "claims", - "electronicHealthRecord", + "administrativeClaims" + ], + "measureSets": [], + "measureSpecification": {} + } + ], + "administrativeClaimsMeasures": [] + }, + { + "mvpId": "G0055", + "clinicalTopic": "Heart Disease", + "title": "Advancing Care for Heart Disease", + "description": "The Advancing Care for Heart Disease MVP focuses on the clinical theme of providing fundamental treatment and management of costly clinical conditions that contribute to, or may result from, heart disease.", + "specialtiesMostApplicableTo": [ + "Cardiology", + "Internal Medicine", + "Family Medicine" + ], + "clinicalTopics": "Heart Disease", + "allowedVendors": [], + "hasCahps": false, + "hasOutcomeAdminClaims": true, + "qualityMeasures": [ + { + "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", + "eMeasureId": "CMS135v11", + "nqfEMeasureId": "0081e", + "nqfId": "0081", + "measureId": "005", + "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0055" + ], + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "cardiology", + "familyMedicine", + "hospitalists", + "internalMedicine" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_005_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms135v11" + } + }, + { + "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", + "eMeasureId": "CMS145v11", + "nqfEMeasureId": "0070e", + "nqfId": "0070", + "measureId": "007", + "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker therapy.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0055" + ], + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "cardiology", + "familyMedicine", + "internalMedicine", + "skilledNursingFacility" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_007_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms145v11" + } + }, + { + "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", + "eMeasureId": "CMS144v11", + "nqfEMeasureId": "0083e", + "nqfId": "0083", + "measureId": "008", + "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0055" + ], + "submissionMethods": [ + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "cardiology", + "familyMedicine", + "hospitalists", + "internalMedicine", + "skilledNursingFacility" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_008_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms144v11" + } + }, + { + "title": "Advance Care Plan", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0326", + "measureId": "047", + "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054", + "G0055", + "G0056", + "M0001", + "M0002", + "M0003", + "M0004" + ], + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "cardiology", + "certifiedNurseMidwife", + "clinicalSocialWork", + "familyMedicine", + "gastroenterology", + "generalSurgery", + "geriatrics", + "hospitalists", + "internalMedicine", + "nephrology", + "neurology", + "obstetricsGynecology", + "oncology", + "orthopedicSurgery", + "otolaryngology", + "physicalMedicine", + "preventiveMedicine", + "pulmonology", + "rheumatology", + "skilledNursingFacility", + "thoracicSurgery", + "urology", + "vascularSurgery" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" + } + }, + { + "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", + "eMeasureId": "CMS69v11", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "128", + "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0055", + "G0058", + "M0005" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", "registry" ], "measureSets": [ @@ -4022,34 +4662,25 @@ "M0003", "M0004" ] - } - ], - "foundationQualityMeasures": [ + }, { - "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "479", - "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2021, + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -4062,38 +4693,26 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} + ] }, { - "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "484", - "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2022, + "category": "pi", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -4106,221 +4725,279 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} - } - ], - "administrativeClaimsMeasures": [ + ] + }, { - "title": "Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "3612", - "measureId": "492", - "description": "Annual risk-standardized rate of acute, unplanned cardiovascular-related admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with heart failure (HF) or cardiomyopathy.", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", - "allowedPrograms": [ - "mips", - "pcf", - "G0055" - ], - "submissionMethods": [ - "administrativeClaims" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" ], "measureSets": [], - "measureSpecification": null - } - ] - }, - { - "mvpId": "G0056", - "clinicalTopic": "Chronic Disease Management", - "title": "Optimizing Chronic Disease Management", - "description": "The Optimizing Chronic Disease Management MVP focuses on the clinical theme of providing fundamental treatment and management of chronic disease such as diabetes, coronary artery disease, chronic obstructive disease, and major adult depression.", - "specialtiesMostApplicableTo": [ - "Cardiology", - "Internal Medicine", - "Family Medicine" - ], - "clinicalTopics": "Chronic Disease Management", - "allowedVendors": [], - "hasCahps": true, - "hasOutcomeAdminClaims": false, - "qualityMeasures": [ + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, { - "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "0067", - "measureId": "006", - "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0056" - ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "cardiology", - "familyMedicine", - "internalMedicine", - "skilledNursingFacility" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_006_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Advance Care Plan", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "0326", - "measureId": "047", - "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", + "G0053", "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", "M0002", "M0003", "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" ], - "submissionMethods": [ - "claims", - "registry" - ], - "measureSets": [ - "cardiology", - "certifiedNurseMidwife", - "clinicalSocialWork", - "familyMedicine", - "gastroenterology", - "generalSurgery", - "geriatrics", - "hospitalists", - "internalMedicine", - "nephrology", - "neurology", - "obstetricsGynecology", - "oncology", - "orthopedicSurgery", - "otolaryngology", - "physicalMedicine", - "preventiveMedicine", - "pulmonology", - "rheumatology", - "skilledNursingFacility", - "thoracicSurgery", - "urology", - "vascularSurgery" - ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment", - "eMeasureId": "CMS161v11", - "nqfEMeasureId": "0104e", - "nqfId": null, - "measureId": "107", - "description": "Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "Mathematica", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0056" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" ], - "submissionMethods": [ - "electronicHealthRecord" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" ], - "measureSets": [ - "emergencyMedicine", - "familyMedicine", - "internalMedicine", - "mentalBehavioralHealth" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" ], - "measureSpecification": { - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms161v11" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + } + ], + "foundationQualityMeasures": [ + { + "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": "0066", - "measureId": "118", - "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB therapy.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American Heart Association", - "firstPerformanceYear": 2017, + "nqfId": null, + "measureId": "479", + "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", + "measureType": "outcome", + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -4328,37 +5005,43 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", - "G0056" + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ - "registry" - ], - "measureSets": [ - "cardiology", - "endocrinology", - "skilledNursingFacility" + "administrativeClaims" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_118_MIPSCQM.pdf" - } + "measureSets": [], + "measureSpecification": {} }, { - "title": "Controlling High Blood Pressure", - "eMeasureId": "CMS165v11", + "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", + "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "measureId": "236", - "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", - "measureType": "intermediateOutcome", + "measureId": "484", + "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", + "measureType": "outcome", "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -4366,47 +5049,91 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", "app1", + "G0053", "G0054", + "G0055", "G0056", - "M0002" - ], - "submissionMethods": [ - "claims", - "electronicHealthRecord", - "cmsWebInterface", - "registry" + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], - "measureSets": [ - "cardiology", - "endocrinology", - "familyMedicine", - "internalMedicine", - "obstetricsGynecology", - "pulmonology", - "rheumatology", - "vascularSurgery" + "submissionMethods": [ + "administrativeClaims" ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" - } - }, + "measureSets": [], + "measureSpecification": {} + } + ], + "administrativeClaimsMeasures": [ { - "title": "CAHPS for MIPS Clinician/Group Survey", + "title": "Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System", "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": "0005", - "measureId": "321", - "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", - "measureType": "patientEngagementExperience", + "nqfId": "3612", + "measureId": "492", + "description": "Annual risk-standardized rate of acute, unplanned cardiovascular-related admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with heart failure (HF) or cardiomyopathy.", + "measureType": "outcome", "isHighPriority": true, - "primarySteward": "Agency for Healthcare Research & Quality", + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "isInverse": true, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "costScore", + "allowedPrograms": [ + "mips", + "pcf", + "G0055" + ], + "submissionMethods": [ + "administrativeClaims" + ], + "measureSets": [], + "measureSpecification": null + } + ] + }, + { + "mvpId": "G0056", + "clinicalTopic": "Chronic Disease Management", + "title": "Optimizing Chronic Disease Management", + "description": "The Optimizing Chronic Disease Management MVP focuses on the clinical theme of providing fundamental treatment and management of chronic disease such as diabetes, coronary artery disease, chronic obstructive disease, and major adult depression.", + "specialtiesMostApplicableTo": [ + "Cardiology", + "Internal Medicine", + "Family Medicine" + ], + "clinicalTopics": "Chronic Disease Management", + "allowedVendors": [], + "hasCahps": true, + "hasOutcomeAdminClaims": false, + "qualityMeasures": [ + { + "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0067", + "measureId": "006", + "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, @@ -4417,37 +5144,35 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "cahps", + "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", - "app1", - "G0056", - "G0057", - "M0001", - "M0005" + "G0056" ], "submissionMethods": [ - "certifiedSurveyVendor" + "registry" ], "measureSets": [ + "cardiology", "familyMedicine", "internalMedicine", - "oncology", - "urology" + "skilledNursingFacility" ], - "measureSpecification": {} + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_006_MIPSCQM.pdf" + } }, { - "title": "Optimal Asthma Control", + "title": "Advance Care Plan", "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": null, - "measureId": "398", - "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.", - "measureType": "outcome", + "nqfId": "0326", + "measureId": "047", + "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", + "measureType": "process", "isHighPriority": true, - "primarySteward": "Minnesota Community Measurement", + "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, @@ -4458,68 +5183,62 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "multiPerformanceRate", + "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", - "G0056" + "G0054", + "G0055", + "G0056", + "M0001", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ + "claims", "registry" ], "measureSets": [ - "allergyImmunology", + "cardiology", + "certifiedNurseMidwife", + "clinicalSocialWork", "familyMedicine", + "gastroenterology", + "generalSurgery", + "geriatrics", + "hospitalists", "internalMedicine", + "nephrology", + "neurology", + "obstetricsGynecology", + "oncology", + "orthopedicSurgery", "otolaryngology", - "pediatrics", - "pulmonology" + "physicalMedicine", + "preventiveMedicine", + "pulmonology", + "rheumatology", + "skilledNursingFacility", + "thoracicSurgery", + "urology", + "vascularSurgery" ], "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_398_MIPSCQM.pdf" - }, - "overallAlgorithm": "overallStratumOnly", - "strata": [ - { - "name": "overall", - "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation" - }, - { - "name": "pedCtrlNoExacRisk", - "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation" - }, - { - "name": "adultCtrlNoExacRisk", - "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation" - }, - { - "name": "pedsWellCtrl", - "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma" - }, - { - "name": "adultsWellCtrl", - "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma" - }, - { - "name": "pedsNoRiskExac", - "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma" - }, - { - "name": "adultsNoRiskExac", - "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma" - } - ] + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" + } }, { - "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", - "eMeasureId": "CMS347v6", - "nqfEMeasureId": null, + "title": "Adult Major Depressive Disorder (MDD): Suicide Risk Assessment", + "eMeasureId": "CMS161v11", + "nqfEMeasureId": "0104e", "nqfId": null, - "measureId": "438", - "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: \n*All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR \n*Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR \n*Patients aged 40-75 years with a diagnosis of diabetes", + "measureId": "107", + "description": "Percentage of all patient visits for those patients that turn 18 or older during the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit", "measureType": "process", "isHighPriority": false, - "primarySteward": "Centers for Medicare & Medicaid Services", + "primarySteward": "Mathematica", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, @@ -4534,37 +5253,32 @@ "allowedPrograms": [ "mips", "pcf", - "G0054", "G0056" ], "submissionMethods": [ - "electronicHealthRecord", - "cmsWebInterface", - "registry" + "electronicHealthRecord" ], "measureSets": [ - "cardiology", - "endocrinology", + "emergencyMedicine", "familyMedicine", "internalMedicine", - "preventiveMedicine" + "mentalBehavioralHealth" ], "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_438_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms347v6" + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms161v11" } }, { - "title": "Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)", + "title": "Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": "3568", - "measureId": "483", - "description": "The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.", - "measureType": "patientReportedOutcome", - "isHighPriority": true, - "primarySteward": "The American Board of Family Medicine", - "firstPerformanceYear": 2022, + "nqfId": "0066", + "measureId": "118", + "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB therapy.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American Heart Association", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": false, "category": "quality", @@ -4574,33 +5288,279 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "nonProportion", + "metricType": "singlePerformanceRate", "allowedPrograms": [ "mips", "pcf", - "G0056", - "M0005" + "G0056" ], "submissionMethods": [ "registry" ], "measureSets": [ - "familyMedicine", - "internalMedicine" + "cardiology", + "endocrinology", + "skilledNursingFacility" ], "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_483_MIPSCQM.pdf" + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_118_MIPSCQM.pdf" } - } - ], - "iaMeasures": [ + }, { - "category": "ia", - "title": "Promote Use of Patient-Reported Outcome Tools", - "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", - "measureId": "IA_AHE_3", - "metricType": "boolean", - "firstPerformanceYear": 2017, + "title": "Controlling High Blood Pressure", + "eMeasureId": "CMS165v11", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "236", + "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "app1", + "G0054", + "G0056", + "M0002" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [ + "cardiology", + "endocrinology", + "familyMedicine", + "internalMedicine", + "obstetricsGynecology", + "pulmonology", + "rheumatology", + "vascularSurgery" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" + } + }, + { + "title": "CAHPS for MIPS Clinician/Group Survey", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0005", + "measureId": "321", + "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "cahps", + "allowedPrograms": [ + "mips", + "pcf", + "app1", + "G0056", + "G0057", + "M0001", + "M0005" + ], + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "familyMedicine", + "internalMedicine", + "oncology", + "urology" + ], + "measureSpecification": {} + }, + { + "title": "Optimal Asthma Control", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "398", + "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.", + "measureType": "outcome", + "isHighPriority": true, + "primarySteward": "Minnesota Community Measurement", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "multiPerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0056" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "familyMedicine", + "internalMedicine", + "otolaryngology", + "pediatrics", + "pulmonology" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_398_MIPSCQM.pdf" + }, + "overallAlgorithm": "overallStratumOnly", + "strata": [ + { + "name": "overall", + "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation" + }, + { + "name": "pedCtrlNoExacRisk", + "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation" + }, + { + "name": "adultCtrlNoExacRisk", + "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation" + }, + { + "name": "pedsWellCtrl", + "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma" + }, + { + "name": "adultsWellCtrl", + "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma" + }, + { + "name": "pedsNoRiskExac", + "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma" + }, + { + "name": "adultsNoRiskExac", + "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma" + } + ] + }, + { + "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", + "eMeasureId": "CMS347v6", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "438", + "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: \n*All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR \n*Patients aged >= 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR \n*Patients aged 40-75 years with a diagnosis of diabetes", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054", + "G0056" + ], + "submissionMethods": [ + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [ + "cardiology", + "endocrinology", + "familyMedicine", + "internalMedicine", + "preventiveMedicine" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_438_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms347v6" + } + }, + { + "title": "Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "3568", + "measureId": "483", + "description": "The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.", + "measureType": "patientReportedOutcome", + "isHighPriority": true, + "primarySteward": "The American Board of Family Medicine", + "firstPerformanceYear": 2022, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "nonProportion", + "allowedPrograms": [ + "mips", + "pcf", + "G0056", + "M0005" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "familyMedicine", + "internalMedicine" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_483_MIPSCQM.pdf" + } + } + ], + "iaMeasures": [ + { + "category": "ia", + "title": "Promote Use of Patient-Reported Outcome Tools", + "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", + "measureId": "IA_AHE_3", + "metricType": "boolean", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", "subcategoryId": "achievingHealthEquity", @@ -5457,34 +6417,25 @@ "M0003", "M0004" ] - } - ], - "foundationQualityMeasures": [ + }, { - "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "479", - "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2021, + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -5497,38 +6448,26 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} + ] }, { - "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "484", - "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2022, + "category": "pi", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -5541,158 +6480,277 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} - } - ], - "administrativeClaimsMeasures": [] - }, - { - "mvpId": "G0057", - "clinicalTopic": "Emergency Medicine", - "title": "Adopting Best Practices and Promoting Patient Safety within Emergency Medicine", - "description": "The Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP focuses on important assessors of the care emergency clinicians provide to patients with undifferentiated high-risk conditions. By focusing on these specific measures and activities, emergency clinicians can reduce clinical variability, improve the quality of emergency care and potentially lower costs.", - "specialtiesMostApplicableTo": [ - "Emergency Medicine" - ], - "clinicalTopics": "Emergency Medicine", - "allowedVendors": [], - "hasCahps": true, - "hasOutcomeAdminClaims": false, - "qualityMeasures": [ + ] + }, { - "title": "Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "0058", - "measureId": "116", - "description": "The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0057" - ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "emergencyMedicine", - "familyMedicine", - "internalMedicine", - "pediatrics", - "preventiveMedicine", - "urgentCare" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_116_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "254", - "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "American College of Emergency Physicians", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0057" - ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "emergencyMedicine" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_254_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "CAHPS for MIPS Clinician/Group Survey", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "0005", - "measureId": "321", - "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", - "measureType": "patientEngagementExperience", - "isHighPriority": true, - "primarySteward": "Agency for Healthcare Research & Quality", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "cahps", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", + "G0053", + "G0054", + "G0055", "G0056", "G0057", + "G0058", + "G0059", "M0001", - "M0005" + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" ], - "submissionMethods": [ - "certifiedSurveyVendor" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" ], - "measureSets": [ - "familyMedicine", - "internalMedicine", - "oncology", - "urology" + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" ], - "measureSpecification": {} + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", + "category": "pi", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + } + ], + "foundationQualityMeasures": [ + { + "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "measureId": "331", - "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.", - "measureType": "process", + "measureId": "479", + "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", + "measureType": "outcome", "isHighPriority": true, - "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", - "firstPerformanceYear": 2017, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, "category": "quality", @@ -5702,40 +6760,43 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", - "G0057" + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ - "registry" - ], - "measureSets": [ - "allergyImmunology", - "emergencyMedicine", - "familyMedicine", - "internalMedicine", - "otolaryngology", - "urgentCare" + "administrativeClaims" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_331_MIPSCQM.pdf" - } + "measureSets": [], + "measureSpecification": {} }, { - "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", + "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, - "measureId": "415", - "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.", - "measureType": "efficiency", + "measureId": "484", + "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", + "measureType": "outcome", "isHighPriority": true, - "primarySteward": "American College of Emergency Physicians", - "firstPerformanceYear": 2017, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -5743,26 +6804,245 @@ "isClinicalGuidelineChanged": false, "isIcdImpacted": false, "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "metricType": "costScore", "allowedPrograms": [ "mips", "pcf", - "G0057" + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ], "submissionMethods": [ - "registry" - ], - "measureSets": [ - "emergencyMedicine" + "administrativeClaims" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_415_MIPSCQM.pdf" - } - }, + "measureSets": [], + "measureSpecification": {} + } + ], + "administrativeClaimsMeasures": [] + }, + { + "mvpId": "G0057", + "clinicalTopic": "Emergency Medicine", + "title": "Adopting Best Practices and Promoting Patient Safety within Emergency Medicine", + "description": "The Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP focuses on important assessors of the care emergency clinicians provide to patients with undifferentiated high-risk conditions. By focusing on these specific measures and activities, emergency clinicians can reduce clinical variability, improve the quality of emergency care and potentially lower costs.", + "specialtiesMostApplicableTo": [ + "Emergency Medicine" + ], + "clinicalTopics": "Emergency Medicine", + "allowedVendors": [], + "hasCahps": true, + "hasOutcomeAdminClaims": false, + "qualityMeasures": [ { - "measureId": "ACEP21", - "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", - "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider", + "title": "Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0058", + "measureId": "116", + "description": "The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0057" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "emergencyMedicine", + "familyMedicine", + "internalMedicine", + "pediatrics", + "preventiveMedicine", + "urgentCare" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_116_MIPSCQM.pdf" + } + }, + { + "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "254", + "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "American College of Emergency Physicians", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0057" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "emergencyMedicine" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_254_MIPSCQM.pdf" + } + }, + { + "title": "CAHPS for MIPS Clinician/Group Survey", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0005", + "measureId": "321", + "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)\n• How well Providers Communicate; (Not endorsed by NQF)\n• Patient’s Rating of Provider; (NQF endorsed # 0005)\n• Access to Specialists; (Not endorsed by NQF)\n• Health Promotion and Education; (Not endorsed by NQF)\n• Shared Decision-Making; (Not endorsed by NQF) \n• Health Status and Functional Status; (Not endorsed by NQF)\n• Courteous and Helpful Office Staff; (NQF endorsed # 0005)\n• Care Coordination; (Not endorsed by NQF)\n• Stewardship of Patient Resources. (Not endorsed by NQF)", + "measureType": "patientEngagementExperience", + "isHighPriority": true, + "primarySteward": "Agency for Healthcare Research & Quality", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "cahps", + "allowedPrograms": [ + "mips", + "pcf", + "app1", + "G0056", + "G0057", + "M0001", + "M0005" + ], + "submissionMethods": [ + "certifiedSurveyVendor" + ], + "measureSets": [ + "familyMedicine", + "internalMedicine", + "oncology", + "urology" + ], + "measureSpecification": {} + }, + { + "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "331", + "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": true, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0057" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "allergyImmunology", + "emergencyMedicine", + "familyMedicine", + "internalMedicine", + "otolaryngology", + "urgentCare" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_331_MIPSCQM.pdf" + } + }, + { + "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "415", + "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.", + "measureType": "efficiency", + "isHighPriority": true, + "primarySteward": "American College of Emergency Physicians", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0057" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "emergencyMedicine" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_415_MIPSCQM.pdf" + } + }, + { + "measureId": "ACEP21", + "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding", + "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider", "nqfId": null, "measureType": "process", "isHighPriority": true, @@ -6650,34 +7930,25 @@ "M0003", "M0004" ] - } - ], - "foundationQualityMeasures": [ + }, { - "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "479", - "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2021, + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -6690,38 +7961,26 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} + ] }, { - "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "484", - "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", - "measureType": "outcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2022, + "category": "pi", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "costScore", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", - "app1", "G0053", "G0054", "G0055", @@ -6734,292 +7993,130 @@ "M0002", "M0003", "M0004" - ], - "submissionMethods": [ - "administrativeClaims" - ], - "measureSets": [], - "measureSpecification": {} - } - ], - "administrativeClaimsMeasures": [] - }, - { - "mvpId": "G0058", - "clinicalTopic": "Lower Extremity Joint Repair", - "title": "Improving Care for Lower Extremity Joint Repair", - "description": "The Improving Care for Lower Extremity Joint Repair MVP focuses on the clinical theme of providing fundamental treatment and management of patients with osteoarthritis and lower extremity surgical repair, such as fracture and total joint replacement, to ensure appropriate care and reduce costs.", - "specialtiesMostApplicableTo": [ - "Orthopedic Surgery" - ], - "clinicalTopics": "Lower Extremity Joint Repair", - "allowedVendors": [], - "hasCahps": false, - "hasOutcomeAdminClaims": true, - "qualityMeasures": [ + ] + }, { - "title": "Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "024", - "description": "Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0058" - ], - "submissionMethods": [ - "claims", - "registry" - ], - "measureSets": [ - "familyMedicine", - "internalMedicine", - "orthopedicSurgery", - "preventiveMedicine", - "rheumatology" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_024_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_024_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", - "eMeasureId": "CMS69v11", - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "128", - "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "mips", - "pcf", + "G0053", + "G0054", "G0055", + "G0056", + "G0057", "G0058", - "M0005" - ], - "submissionMethods": [ - "claims", - "electronicHealthRecord", - "registry" - ], - "measureSets": [ - "cardiology", - "endocrinology", - "familyMedicine", - "gastroenterology", - "generalSurgery", - "internalMedicine", - "mentalBehavioralHealth", - "nutritionDietician", - "obstetricsGynecology", - "orthopedicSurgery", - "otolaryngology", - "physicalMedicine", - "physicalTherapyOccupationalTherapy", - "plasticSurgery", - "podiatry", - "preventiveMedicine", - "pulmonology", - "rheumatology", - "urology", - "vascularSurgery" - ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_128_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_128_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms069v11" - } + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "350", - "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "American Association of Hip and Knee Surgeons", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0058" - ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "orthopedicSurgery" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_350_MIPSCQM.pdf" - } + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] }, { - "title": "Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "351", - "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "American Association of Hip and Knee Surgeons", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0058" - ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "orthopedicSurgery" - ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_351_MIPSCQM.pdf" - } - }, - { - "title": "Functional Status Assessment for Total Hip Replacement", - "eMeasureId": "CMS56v11", - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "376", - "description": "Percentage of patients 19 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270 – 365 days after the surgery.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0058" - ], - "submissionMethods": [ - "electronicHealthRecord" - ], - "measureSets": [ - "orthopedicSurgery" - ], - "measureSpecification": { - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms056v11" - } - }, - { - "title": "Functional Status After Primary Total Knee Replacement", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "470", - "description": "For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.", - "measureType": "patientReportedOutcome", - "isHighPriority": true, - "primarySteward": "Minnesota Community Measurement", - "firstPerformanceYear": 2019, - "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "G0058" - ], - "submissionMethods": [ - "registry" - ], - "measureSets": [ - "orthopedicSurgery" + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_470_MIPSCQM.pdf" - } - } - ], - "iaMeasures": [ - { - "category": "ia", - "title": "Promote Use of Patient-Reported Outcome Tools", - "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", - "measureId": "IA_AHE_3", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "achievingHealthEquity", + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", + "G0054", + "G0055", "G0056", + "G0057", "G0058", + "G0059", + "M0001", "M0005", "M0002", "M0003", @@ -7027,112 +8124,118 @@ ] }, { - "category": "ia", - "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", - "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", - "measureId": "IA_BE_6", + "category": "pi", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "beneficiaryEngagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Use evidence-based decision aids to support shared decision-making.", - "description": "Use evidence-based decision aids to support shared decision-making.", - "measureId": "IA_BE_12", + "category": "pi", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "G0053", + "G0054", "G0055", + "G0056", + "G0057", "G0058", - "M0005" - ] - }, - { - "category": "ia", - "title": "Regular training in care coordination", - "description": "Implementation of regular care coordination training.", - "measureId": "IA_CC_7", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", - "allowedPrograms": [ - "G0058" - ] - }, - { - "category": "ia", - "title": "Implementation of practices/processes for developing regular individual care plans", - "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.", - "measureId": "IA_CC_9", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", - "allowedPrograms": [ - "G0055", - "G0058" + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Practice Improvements to Align with OpenNotes Principles", - "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", - "measureId": "IA_CC_13", + "category": "pi", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "G0053", "G0054", + "G0055", "G0056", + "G0057", "G0058", + "G0059", + "M0001", "M0005", - "M0002" - ] - }, - { - "category": "ia", - "title": "PSH Care Coordination", - "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", - "measureId": "IA_CC_15", - "metricType": "boolean", - "firstPerformanceYear": 2018, - "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "careCoordination", - "allowedPrograms": [ - "G0058", - "G0059" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", "G0054", @@ -7147,118 +8250,33 @@ "M0003", "M0004" ] - }, - { - "category": "ia", - "title": "Use of QCDR data for ongoing practice assessment and improvements", - "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", - "measureId": "IA_PSPA_7", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "G0055", - "G0056", - "G0057", - "G0058", - "G0059" - ] - }, - { - "category": "ia", - "title": "Measurement and improvement at the practice and panel level", - "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards that could include one or more of the following:•\tRegularly review measures of quality, utilization, patient satisfaction and other measures; and/or•\tUse relevant data sources to create benchmarks and goals for performance at the practice or panel levels.MIPS eligible clinicians can apply the measurement and quality improvement to address inequities in quality and outcomes for underserved populations, including racial, ethnic, and/or gender minorities.", - "measureId": "IA_PSPA_18", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "G0058" - ] - }, - { - "category": "ia", - "title": "Invasive Procedure or Surgery Anticoagulation Medication Management", - "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.", - "measureId": "IA_PSPA_27", - "metricType": "boolean", - "firstPerformanceYear": 2018, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "G0058" - ] } ], - "costMeasures": [ + "foundationQualityMeasures": [ { - "category": "cost", - "title": "Knee Arthroplasty", - "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Knee Arthroplasty episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive an elective knee arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", - "measureId": "COST_KA_1", - "metricType": "costScore", - "firstPerformanceYear": 2019, + "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "479", + "description": "This measure is a re-specified version of the measure, \"Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition\" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", + "measureType": "outcome", + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" - ], - "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-knee-arthro.pdf" - }, - "allowedPrograms": [ - "G0058" - ] - }, - { - "category": "cost", - "title": "Elective Primary Hip Arthroplasty", - "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who receive an elective primary hip arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", - "measureId": "COST_PHA_1", + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], "metricType": "costScore", - "firstPerformanceYear": 2020, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": null, - "submissionMethods": [ - "administrativeClaims" - ], - "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-el-ha.pdf" - }, - "allowedPrograms": [ - "G0058" - ] - } - ], - "foundationPiMeasures": [ - { - "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", - "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_LVPP_1" - ], "allowedPrograms": [ + "mips", + "pcf", "app1", "G0053", "G0054", @@ -7272,31 +8290,37 @@ "M0002", "M0003", "M0004" - ] + ], + "submissionMethods": [ + "administrativeClaims" + ], + "measureSets": [], + "measureSpecification": {} }, { - "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, - "metricType": "boolean", - "firstPerformanceYear": 2019, + "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "484", + "description": "Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).", + "measureType": "outcome", + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "isInverse": true, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "costScore", "allowedPrograms": [ + "mips", + "pcf", "app1", "G0053", "G0054", @@ -7310,69 +8334,860 @@ "M0002", "M0003", "M0004" - ] - }, + ], + "submissionMethods": [ + "administrativeClaims" + ], + "measureSets": [], + "measureSpecification": {} + } + ], + "administrativeClaimsMeasures": [] + }, + { + "mvpId": "G0058", + "clinicalTopic": "Lower Extremity Joint Repair", + "title": "Improving Care for Lower Extremity Joint Repair", + "description": "The Improving Care for Lower Extremity Joint Repair MVP focuses on the clinical theme of providing fundamental treatment and management of patients with osteoarthritis and lower extremity surgical repair, such as fracture and total joint replacement, to ensure appropriate care and reduce costs.", + "specialtiesMostApplicableTo": [ + "Orthopedic Surgery" + ], + "clinicalTopics": "Lower Extremity Joint Repair", + "allowedVendors": [], + "hasCahps": false, + "hasOutcomeAdminClaims": true, + "qualityMeasures": [ { - "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", - "isRequired": true, - "metricType": "proportion", + "title": "Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "024", + "description": "Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0058" ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" + "submissionMethods": [ + "claims", + "registry" ], - "allowedPrograms": [ - "app1", - "G0053", - "G0054", - "G0055", - "G0056", - "G0057", - "G0058", - "G0059", - "M0001", - "M0005", - "M0002", - "M0003", - "M0004" - ] - }, + "measureSets": [ + "familyMedicine", + "internalMedicine", + "orthopedicSurgery", + "preventiveMedicine", + "rheumatology" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_024_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_024_MIPSCQM.pdf" + } + }, + { + "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", + "eMeasureId": "CMS69v11", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "128", + "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0055", + "G0058", + "M0005" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "registry" + ], + "measureSets": [ + "cardiology", + "endocrinology", + "familyMedicine", + "gastroenterology", + "generalSurgery", + "internalMedicine", + "mentalBehavioralHealth", + "nutritionDietician", + "obstetricsGynecology", + "orthopedicSurgery", + "otolaryngology", + "physicalMedicine", + "physicalTherapyOccupationalTherapy", + "plasticSurgery", + "podiatry", + "preventiveMedicine", + "pulmonology", + "rheumatology", + "urology", + "vascularSurgery" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_128_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_128_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms069v11" + } + }, + { + "title": "Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "350", + "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "American Association of Hip and Knee Surgeons", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0058" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_350_MIPSCQM.pdf" + } + }, + { + "title": "Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "351", + "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "American Association of Hip and Knee Surgeons", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0058" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_351_MIPSCQM.pdf" + } + }, + { + "title": "Functional Status Assessment for Total Hip Replacement", + "eMeasureId": "CMS56v11", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "376", + "description": "Percentage of patients 19 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270 – 365 days after the surgery.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0058" + ], + "submissionMethods": [ + "electronicHealthRecord" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "measureSpecification": { + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms056v11" + } + }, + { + "title": "Functional Status After Primary Total Knee Replacement", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "470", + "description": "For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.", + "measureType": "patientReportedOutcome", + "isHighPriority": true, + "primarySteward": "Minnesota Community Measurement", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0058" + ], + "submissionMethods": [ + "registry" + ], + "measureSets": [ + "orthopedicSurgery" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_470_MIPSCQM.pdf" + } + } + ], + "iaMeasures": [ + { + "category": "ia", + "title": "Promote Use of Patient-Reported Outcome Tools", + "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", + "measureId": "IA_AHE_3", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "achievingHealthEquity", + "allowedPrograms": [ + "G0053", + "G0056", + "G0058", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", + "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", + "measureId": "IA_BE_6", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "Use evidence-based decision aids to support shared decision-making.", + "description": "Use evidence-based decision aids to support shared decision-making.", + "measureId": "IA_BE_12", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0055", + "G0058", + "M0005" + ] + }, + { + "category": "ia", + "title": "Regular training in care coordination", + "description": "Implementation of regular care coordination training.", + "measureId": "IA_CC_7", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0058" + ] + }, + { + "category": "ia", + "title": "Implementation of practices/processes for developing regular individual care plans", + "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.", + "measureId": "IA_CC_9", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0055", + "G0058" + ] + }, + { + "category": "ia", + "title": "Practice Improvements to Align with OpenNotes Principles", + "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", + "measureId": "IA_CC_13", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0054", + "G0056", + "G0058", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "PSH Care Coordination", + "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", + "measureId": "IA_CC_15", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0058", + "G0059" + ] + }, + { + "category": "ia", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": null, + "subcategoryId": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Use of QCDR data for ongoing practice assessment and improvements", + "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", + "measureId": "IA_PSPA_7", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0055", + "G0056", + "G0057", + "G0058", + "G0059" + ] + }, + { + "category": "ia", + "title": "Measurement and improvement at the practice and panel level", + "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards that could include one or more of the following:•\tRegularly review measures of quality, utilization, patient satisfaction and other measures; and/or•\tUse relevant data sources to create benchmarks and goals for performance at the practice or panel levels.MIPS eligible clinicians can apply the measurement and quality improvement to address inequities in quality and outcomes for underserved populations, including racial, ethnic, and/or gender minorities.", + "measureId": "IA_PSPA_18", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0058" + ] + }, + { + "category": "ia", + "title": "Invasive Procedure or Surgery Anticoagulation Medication Management", + "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.", + "measureId": "IA_PSPA_27", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0058" + ] + } + ], + "costMeasures": [ + { + "category": "cost", + "title": "Knee Arthroplasty", + "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Knee Arthroplasty episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive an elective knee arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", + "measureId": "COST_KA_1", + "metricType": "costScore", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": "simpleAverage", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-knee-arthro.pdf" + }, + "allowedPrograms": [ + "G0058" + ] + }, + { + "category": "cost", + "title": "Elective Primary Hip Arthroplasty", + "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who receive an elective primary hip arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", + "measureId": "COST_PHA_1", + "metricType": "costScore", + "firstPerformanceYear": 2020, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": null, + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-el-ha.pdf" + }, + "allowedPrograms": [ + "G0058" + ] + } + ], + "foundationPiMeasures": [ + { + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2021, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" + }, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ - "PI_LVITC_2" + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "app1", @@ -7392,21 +9207,87 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], "exclusion": null, @@ -7428,24 +9309,54 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "attestation", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": null, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", "G0054", @@ -7463,24 +9374,53 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "attestation", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": null, + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7497,28 +9437,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7535,24 +9469,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7569,28 +9501,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7607,24 +9533,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7641,24 +9565,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7675,24 +9597,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7709,24 +9629,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -7743,18 +9661,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -7774,18 +9693,19 @@ }, { "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -8197,152 +10117,485 @@ "3471690" ], "allowedPrograms": [ - "mips", - "pcf", + "mips", + "pcf", + "G0059" + ], + "category": "quality", + "lastPerformanceYear": null, + "eMeasureId": null, + "nqfEMeasureId": null, + "measureSets": [], + "isRegistryMeasure": true, + "isIcdImpacted": false, + "metricType": "registrySinglePerformanceRate", + "submissionMethods": [ + "registry" + ] + } + ], + "iaMeasures": [ + { + "category": "ia", + "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", + "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", + "measureId": "IA_BE_6", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "Improved Practices that Engage Patients Pre-Visit", + "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.", + "measureId": "IA_BE_22", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0056", + "G0059" + ] + }, + { + "category": "ia", + "title": "Tobacco use", + "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", + "measureId": "IA_BMH_2", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth", + "allowedPrograms": [ + "G0053", + "G0059" + ] + }, + { + "category": "ia", + "title": "Implementation of improvements that contribute to more timely communication of test results", + "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", + "measureId": "IA_CC_2", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0054", + "G0056", + "G0057", + "G0059", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "PSH Care Coordination", + "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", + "measureId": "IA_CC_15", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0058", "G0059" - ], - "category": "quality", + ] + }, + { + "category": "ia", + "title": "Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.", + "description": "To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period. Reporting the PRC modifiers enables the identification of a clinician’s relationship with, and responsibility for, a patient at the time of furnishing an item or service. See the CY 2018 PFS final rule (82 FR 53232 through 53234) for more details on these codes.", + "measureId": "IA_CC_19", + "metricType": "boolean", + "firstPerformanceYear": 2020, "lastPerformanceYear": null, - "eMeasureId": null, - "nqfEMeasureId": null, - "measureSets": [], - "isRegistryMeasure": true, - "isIcdImpacted": false, - "metricType": "registrySinglePerformanceRate", - "submissionMethods": [ - "registry" + "weight": "high", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0059" ] - } - ], - "iaMeasures": [ + }, { "category": "ia", - "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", - "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", - "measureId": "IA_BE_6", + "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", + "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", + "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", - "subcategoryId": "beneficiaryEngagement", + "subcategoryId": "expandedPracticeAccess", + "allowedPrograms": [ + "G0053", + "G0056", + "G0059", + "M0001", + "M0005", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": null, + "subcategoryId": null, "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { "category": "ia", - "title": "Improved Practices that Engage Patients Pre-Visit", - "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.", - "measureId": "IA_BE_22", + "title": "Participation in an AHRQ-listed patient safety organization.", + "description": "Participation in an AHRQ-listed patient safety organization.", + "measureId": "IA_PSPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ - "G0056", + "G0057", "G0059" ] }, { "category": "ia", - "title": "Tobacco use", - "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", - "measureId": "IA_BMH_2", + "title": "Use of QCDR data for ongoing practice assessment and improvements", + "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", + "measureId": "IA_PSPA_7", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "behavioralAndMentalHealth", + "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ - "G0053", + "G0055", + "G0056", + "G0057", + "G0058", "G0059" ] }, { "category": "ia", - "title": "Implementation of improvements that contribute to more timely communication of test results", - "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", - "measureId": "IA_CC_2", + "title": "Use of decision support and standardized treatment protocols", + "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", + "measureId": "IA_PSPA_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0059", + "M0001", + "M0002" + ] + } + ], + "costMeasures": [ + { + "category": "cost", + "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", + "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", + "measureId": "MSPB_1", + "metricType": "costScore", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": "simpleAverage", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" + }, + "allowedPrograms": [ + "G0057", + "G0059", + "M0003", + "M0004" + ] + } + ], + "foundationPiMeasures": [ + { + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, "metricType": "boolean", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], "allowedPrograms": [ + "app1", + "G0053", "G0054", + "G0055", "G0056", "G0057", + "G0058", "G0059", + "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "PSH Care Coordination", - "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", - "measureId": "IA_CC_15", + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2018, + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "careCoordination", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", "G0058", - "G0059" - ] - }, - { - "category": "ia", - "title": "Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.", - "description": "To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period. Reporting the PRC modifiers enables the identification of a clinician’s relationship with, and responsibility for, a patient at the time of furnishing an item or service. See the CY 2018 PFS final rule (82 FR 53232 through 53234) for more details on these codes.", - "measureId": "IA_CC_19", - "metricType": "boolean", - "firstPerformanceYear": 2020, - "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "careCoordination", - "allowedPrograms": [ - "G0059" + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", - "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", - "measureId": "IA_EPA_1", + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", + "G0054", + "G0055", "G0056", + "G0057", + "G0058", "G0059", "M0001", "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", "G0054", "G0055", @@ -8358,101 +10611,133 @@ ] }, { - "category": "ia", - "title": "Participation in an AHRQ-listed patient safety organization.", - "description": "Participation in an AHRQ-listed patient safety organization.", - "measureId": "IA_PSPA_1", + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", "G0057", - "G0059" + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Use of QCDR data for ongoing practice assessment and improvements", - "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", - "measureId": "IA_PSPA_7", + "category": "pi", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", "G0055", "G0056", "G0057", "G0058", - "G0059" - ] - }, - { - "category": "ia", - "title": "Use of decision support and standardized treatment protocols", - "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", - "measureId": "IA_PSPA_16", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ "G0059", "M0001", - "M0002" + "M0005", + "M0002", + "M0003", + "M0004" ] - } - ], - "costMeasures": [ + }, { - "category": "cost", - "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", - "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", - "measureId": "MSPB_1", - "metricType": "costScore", + "category": "pi", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "isRequired": true, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", "G0057", + "G0058", "G0059", + "M0001", + "M0005", + "M0002", "M0003", "M0004" ] - } - ], - "foundationPiMeasures": [ + }, { "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", - "isRequired": true, - "metricType": "proportion", + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVPP_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -8471,26 +10756,22 @@ }, { "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2019, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -8509,27 +10790,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -8548,27 +10824,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVITC_2" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -8587,26 +10858,21 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8623,22 +10889,18 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -8658,24 +10920,22 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2017, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8692,28 +10952,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8730,24 +10984,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8764,28 +11016,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8802,24 +11048,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8836,24 +11080,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8870,24 +11112,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8904,24 +11144,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -8938,18 +11176,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -8969,18 +11208,19 @@ }, { "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -9678,67 +11918,331 @@ ] }, { - "category": "ia", - "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", - "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", - "measureId": "IA_CC_1", + "category": "ia", + "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", + "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", + "measureId": "IA_CC_1", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Patient Navigator Program", + "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", + "measureId": "IA_CC_17", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0054", + "M0001" + ] + }, + { + "category": "ia", + "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", + "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", + "measureId": "IA_EPA_1", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "expandedPracticeAccess", + "allowedPrograms": [ + "G0053", + "G0056", + "G0059", + "M0001", + "M0005", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": null, + "subcategoryId": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", + "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", + "measureId": "IA_PM_14", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "G0055", + "G0056", + "M0001", + "M0002" + ] + }, + { + "category": "ia", + "title": "Implementation of episodic care management practice improvements", + "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or• Managing care intensively through new diagnoses, injuries and exacerbations of illness.", + "measureId": "IA_PM_15", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "G0054", + "M0001" + ] + }, + { + "category": "ia", + "title": "Implementation of medication management practice improvements", + "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", + "measureId": "IA_PM_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "G0053", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Advance Care Planning", + "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", + "measureId": "IA_PM_21", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Use of decision support and standardized treatment protocols", + "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", + "measureId": "IA_PSPA_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0059", + "M0001", + "M0002" + ] + } + ], + "costMeasures": [ + { + "category": "cost", + "title": "Total Per Capita Cost (TPCC)", + "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", + "measureId": "TPCC_1", + "metricType": "costScore", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": "simpleAverage", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" + }, + "allowedPrograms": [ + "G0053", + "G0055", + "G0056", + "M0001", + "M0005", + "M0002" + ] + } + ], + "foundationPiMeasures": [ + { + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2019, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Patient Navigator Program", - "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", - "measureId": "IA_CC_17", - "metricType": "boolean", - "firstPerformanceYear": 2018, - "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "careCoordination", - "allowedPrograms": [ - "G0054", - "M0001" - ] - }, - { - "category": "ia", - "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", - "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", - "measureId": "IA_EPA_1", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", "G0056", + "G0057", + "G0058", "G0059", "M0001", "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", - "metricType": "boolean", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], "allowedPrograms": [ + "app1", "G0053", "G0054", "G0055", @@ -9754,49 +12258,103 @@ ] }, { - "category": "ia", - "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", - "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", - "measureId": "IA_PM_14", + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", - "M0002" + "M0005", + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Implementation of episodic care management practice improvements", - "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or• Managing care intensively through new diagnoses, injuries and exacerbations of illness.", - "measureId": "IA_PM_15", + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "G0053", "G0054", - "M0001" + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Implementation of medication management practice improvements", - "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", - "measureId": "IA_PM_16", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -9805,85 +12363,98 @@ ] }, { - "category": "ia", - "title": "Advance Care Planning", - "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", - "measureId": "IA_PM_21", + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2018, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Use of decision support and standardized treatment protocols", - "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", - "measureId": "IA_PSPA_16", + "category": "pi", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "G0059", - "M0001", - "M0002" - ] - } - ], - "costMeasures": [ - { - "category": "cost", - "title": "Total Per Capita Cost (TPCC)", - "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", - "measureId": "TPCC_1", - "metricType": "costScore", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", + "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] - } - ], - "foundationPiMeasures": [ + }, { "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ - "PI_LVPP_1" + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "app1", @@ -9903,26 +12474,22 @@ }, { "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2019, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -9941,27 +12508,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", - "isRequired": true, - "metricType": "proportion", + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -9980,27 +12542,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVITC_2" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -10019,21 +12576,19 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, @@ -10055,22 +12610,18 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -10090,24 +12641,21 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10124,28 +12672,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PROD" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10162,24 +12704,54 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10196,28 +12768,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10234,24 +12800,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10268,24 +12832,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10302,24 +12864,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10336,24 +12896,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -10370,18 +12928,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -10401,18 +12960,19 @@ }, { "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -11260,50 +13820,181 @@ "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "achievingHealthEquity", + "weight": "high", + "subcategoryId": "achievingHealthEquity", + "allowedPrograms": [ + "G0053", + "G0056", + "G0058", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health", + "description": "Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:\r\n• Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or \r\n• Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or\r\n• Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. \r\n\r\nDrivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.", + "measureId": "IA_AHE_12", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "achievingHealthEquity", + "allowedPrograms": [ + "G0055", + "G0056", + "G0057", + "M0005" + ] + }, + { + "category": "ia", + "title": "Engagement of patients through implementation of improvements in patient portal", + "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", + "measureId": "IA_BE_4", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0053", + "G0054", + "G0056", + "G0057", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", + "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", + "measureId": "IA_BE_6", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "Use evidence-based decision aids to support shared decision-making.", + "description": "Use evidence-based decision aids to support shared decision-making.", + "measureId": "IA_BE_12", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0055", + "G0058", + "M0005" + ] + }, + { + "category": "ia", + "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients", + "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.", + "measureId": "IA_BMH_9", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "behavioralAndMentalHealth", + "allowedPrograms": [ + "M0005" + ] + }, + { + "category": "ia", + "title": "Implementation of improvements that contribute to more timely communication of test results", + "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", + "measureId": "IA_CC_2", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0054", + "G0056", + "G0057", + "G0059", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "Practice Improvements to Align with OpenNotes Principles", + "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", + "measureId": "IA_CC_13", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", "allowedPrograms": [ - "G0053", + "G0054", "G0056", "G0058", "M0005", - "M0002", - "M0003", - "M0004" + "M0002" ] }, { "category": "ia", - "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health", - "description": "Select and screen for drivers of health that are relevant for the eligible clinician’s population using evidence-based tools. If possible, use a screening tool that is health IT-enabled and includes standards-based, coded questions/fields for the capture of data. After screening, address identified drivers of health through at least one of the following:\r\n• Develop and maintain formal relationships with community-based organizations to strengthen the community service referral process, implementing closed-loop referrals where feasible; or \r\n• Work with community partners to provide and/or update a community resource guide for to patients who are found to have and/or be at risk in one or more areas of drivers of health; or\r\n• Record findings of screening and follow up within the electronic health record (EHR); identify screened patients with one or more needs associated with drivers of health and implement approaches to better serve their holistic needs through meaningful linkages to community resources. \r\n\r\nDrivers of health (also referred to as social determinants of health [SDOH] or health-related social needs [HSRN]) prioritized by the practice might include, but are not limited to, the following: food security; housing stability; transportation accessibility; interpersonal safety; legal challenges; and environmental exposures.", - "measureId": "IA_AHE_12", + "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", + "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", + "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", - "subcategoryId": "achievingHealthEquity", + "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ - "G0055", + "G0053", "G0056", - "G0057", - "M0005" + "G0059", + "M0001", + "M0005", + "M0003", + "M0004" ] }, { "category": "ia", - "title": "Engagement of patients through implementation of improvements in patient portal", - "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", - "measureId": "IA_BE_4", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "weight": null, + "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", + "G0055", "G0056", "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -11313,120 +14004,310 @@ }, { "category": "ia", - "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", - "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", - "measureId": "IA_BE_6", + "title": "Regular review practices in place on targeted patient population needs", + "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", + "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "beneficiaryEngagement", + "weight": "medium", + "subcategoryId": "populationManagement", "allowedPrograms": [ - "G0057", - "G0058", - "G0059", - "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { "category": "ia", - "title": "Use evidence-based decision aids to support shared decision-making.", - "description": "Use evidence-based decision aids to support shared decision-making.", - "measureId": "IA_BE_12", + "title": "Chronic Care and Preventative Care Management for Empaneled Patients", + "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", + "measureId": "IA_PM_13", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "subcategoryId": "populationManagement", "allowedPrograms": [ + "G0054", "G0055", - "G0058", + "G0056", "M0005" ] }, { "category": "ia", - "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients", - "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.", - "measureId": "IA_BMH_9", + "title": "Implementation of medication management practice improvements", + "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", + "measureId": "IA_PM_16", "metricType": "boolean", - "firstPerformanceYear": 2018, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "behavioralAndMentalHealth", + "weight": "medium", + "subcategoryId": "populationManagement", "allowedPrograms": [ - "M0005" + "G0053", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ] }, { "category": "ia", - "title": "Implementation of improvements that contribute to more timely communication of test results", - "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", - "measureId": "IA_CC_2", + "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", + "description": "Adopt a formal model for quality improvement and create a culture in which all staff, including leadership, actively participates in improvement activities that could include one or more of the following, such as:\n• Participation in multisource feedback; \n• Train all staff in quality improvement methods;\n• Integrate practice change/quality improvement into staff duties;\n• Engage all staff in identifying and testing practices changes;\n• Designate regular team meetings to review data and plan improvement cycles;\n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;\n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;\n• Participation in Bridges to Excellence;\n• Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", + "measureId": "IA_PSPA_19", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "careCoordination", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0056", + "G0057", + "M0005" + ] + } + ], + "costMeasures": [ + { + "category": "cost", + "title": "Total Per Capita Cost (TPCC)", + "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", + "measureId": "TPCC_1", + "metricType": "costScore", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": "simpleAverage", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" + }, + "allowedPrograms": [ + "G0053", + "G0055", + "G0056", + "M0001", + "M0005", + "M0002" + ] + } + ], + "foundationPiMeasures": [ + { + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], "allowedPrograms": [ + "app1", + "G0053", "G0054", + "G0055", "G0056", "G0057", + "G0058", "G0059", + "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Practice Improvements to Align with OpenNotes Principles", - "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", - "measureId": "IA_CC_13", + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, "metricType": "boolean", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], "allowedPrograms": [ + "app1", + "G0053", "G0054", + "G0055", "G0056", + "G0057", "G0058", + "G0059", + "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", - "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", - "measureId": "IA_EPA_1", + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", "G0056", + "G0057", + "G0058", "G0059", "M0001", "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", "G0054", @@ -11443,16 +14324,33 @@ ] }, { - "category": "ia", - "title": "Regular review practices in place on targeted patient population needs", - "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", - "measureId": "IA_PM_11", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", "M0005", "M0002", "M0003", @@ -11460,34 +14358,70 @@ ] }, { - "category": "ia", - "title": "Chronic Care and Preventative Care Management for Empaneled Patients", - "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", - "measureId": "IA_PM_13", + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", "G0054", "G0055", "G0056", - "M0005" + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Implementation of medication management practice improvements", - "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", - "measureId": "IA_PM_16", + "category": "pi", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -11496,70 +14430,61 @@ ] }, { - "category": "ia", - "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", - "description": "Adopt a formal model for quality improvement and create a culture in which all staff, including leadership, actively participates in improvement activities that could include one or more of the following, such as:\n• Participation in multisource feedback; \n• Train all staff in quality improvement methods;\n• Integrate practice change/quality improvement into staff duties;\n• Engage all staff in identifying and testing practices changes;\n• Designate regular team meetings to review data and plan improvement cycles;\n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;\n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;\n• Participation in Bridges to Excellence;\n• Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", - "measureId": "IA_PSPA_19", + "category": "pi", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "G0056", - "G0057", - "M0005" - ] - } - ], - "costMeasures": [ - { - "category": "cost", - "title": "Total Per Capita Cost (TPCC)", - "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", - "measureId": "TPCC_1", - "metricType": "costScore", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] - } - ], - "foundationPiMeasures": [ + }, { "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", - "isRequired": true, - "metricType": "proportion", + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVPP_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -11578,26 +14503,22 @@ }, { "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2019, - "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -11616,27 +14537,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -11655,27 +14571,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVITC_2" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -11694,26 +14605,21 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11730,22 +14636,18 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -11765,24 +14667,22 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2017, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11799,28 +14699,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11837,24 +14731,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11871,28 +14763,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11909,24 +14795,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11943,24 +14827,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -11977,24 +14859,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -12011,24 +14891,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -12045,18 +14923,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -12074,20 +14953,21 @@ "M0004" ] }, - { - "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + { + "category": "pi", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -12212,18 +15092,279 @@ "hasOutcomeAdminClaims": false, "qualityMeasures": [ { - "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", - "eMeasureId": "CMS122v11", + "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", + "eMeasureId": "CMS122v11", + "nqfEMeasureId": null, + "nqfId": "0059", + "measureId": "001", + "description": "Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.", + "measureType": "intermediateOutcome", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": true, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "app1", + "M0002" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [ + "endocrinology", + "familyMedicine", + "internalMedicine", + "nephrology", + "nutritionDietician", + "preventiveMedicine" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_001_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_001_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms122v11" + } + }, + { + "title": "Advance Care Plan", + "eMeasureId": null, + "nqfEMeasureId": null, + "nqfId": "0326", + "measureId": "047", + "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0054", + "G0055", + "G0056", + "M0001", + "M0002", + "M0003", + "M0004" + ], + "submissionMethods": [ + "claims", + "registry" + ], + "measureSets": [ + "cardiology", + "certifiedNurseMidwife", + "clinicalSocialWork", + "familyMedicine", + "gastroenterology", + "generalSurgery", + "geriatrics", + "hospitalists", + "internalMedicine", + "nephrology", + "neurology", + "obstetricsGynecology", + "oncology", + "orthopedicSurgery", + "otolaryngology", + "physicalMedicine", + "preventiveMedicine", + "pulmonology", + "rheumatology", + "skilledNursingFacility", + "thoracicSurgery", + "urology", + "vascularSurgery" + ], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" + } + }, + { + "title": "Preventive Care and Screening: Influenza Immunization", + "eMeasureId": "CMS147v12", + "nqfEMeasureId": null, + "nqfId": "0041", + "measureId": "110", + "description": "Percentage of patients aged 6 months and older seen for a visit during the measurement period who received an influenza immunization OR who reported previous receipt of an influenza immunization.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "M0002" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "cmsWebInterface", + "registry" + ], + "measureSets": [], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_110_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_110_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms147v12" + } + }, + { + "title": "Pneumococcal Vaccination Status for Older Adults", + "eMeasureId": "CMS127v11", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "111", + "description": "Percentage of patients 66 years of age and older who have received a pneumococcal vaccine.", + "measureType": "process", + "isHighPriority": false, + "primarySteward": "National Committee for Quality Assurance", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "G0053", + "M0002" + ], + "submissionMethods": [ + "claims", + "electronicHealthRecord", + "registry" + ], + "measureSets": [], + "measureSpecification": { + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_111_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_111_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms127v11" + } + }, + { + "title": "Documentation of Current Medications in the Medical Record", + "eMeasureId": "CMS68v12", + "nqfEMeasureId": null, + "nqfId": null, + "measureId": "130", + "description": "Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", + "measureType": "process", + "isHighPriority": true, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": false, + "category": "quality", + "isRegistryMeasure": false, + "isRiskAdjusted": false, + "icdImpacted": [], + "isClinicalGuidelineChanged": false, + "isIcdImpacted": false, + "clinicalGuidelineChanged": [], + "metricType": "singlePerformanceRate", + "allowedPrograms": [ + "mips", + "pcf", + "G0053", + "M0002", + "M0003" + ], + "submissionMethods": [ + "registry", + "electronicHealthRecord" + ], + "measureSets": [ + "allergyImmunology", + "audiology", + "cardiology", + "certifiedNurseMidwife", + "clinicalSocialWork", + "dermatology", + "endocrinology", + "familyMedicine", + "gastroenterology", + "generalSurgery", + "geriatrics", + "hospitalists", + "infectiousDisease", + "internalMedicine", + "mentalBehavioralHealth", + "nephrology", + "neurology", + "neurosurgical", + "nutritionDietician", + "obstetricsGynecology", + "oncology", + "ophthalmology", + "orthopedicSurgery", + "otolaryngology", + "physicalMedicine", + "physicalTherapyOccupationalTherapy", + "plasticSurgery", + "preventiveMedicine", + "pulmonology", + "rheumatology", + "speechLanguagePathology", + "thoracicSurgery", + "urgentCare", + "urology", + "vascularSurgery" + ], + "measureSpecification": { + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_130_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms068v12" + } + }, + { + "title": "Controlling High Blood Pressure", + "eMeasureId": "CMS165v11", "nqfEMeasureId": null, - "nqfId": "0059", - "measureId": "001", - "description": "Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.", + "nqfId": null, + "measureId": "236", + "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": true, + "isInverse": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -12236,6 +15377,8 @@ "mips", "pcf", "app1", + "G0054", + "G0056", "M0002" ], "submissionMethods": [ @@ -12245,32 +15388,34 @@ "registry" ], "measureSets": [ + "cardiology", "endocrinology", "familyMedicine", "internalMedicine", - "nephrology", - "nutritionDietician", - "preventiveMedicine" + "obstetricsGynecology", + "pulmonology", + "rheumatology", + "vascularSurgery" ], "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_001_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_001_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms122v11" + "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", + "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" } }, { - "title": "Advance Care Plan", + "title": "Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate", "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": "0326", - "measureId": "047", - "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", - "measureType": "process", + "nqfId": null, + "measureId": "482", + "description": "Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.", + "measureType": "intermediateOutcome", "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "primarySteward": "Centers for Medicare & Medicaid Services", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "isInverse": false, + "isInverse": true, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, @@ -12282,59 +15427,29 @@ "allowedPrograms": [ "mips", "pcf", - "G0054", - "G0055", - "G0056", - "M0001", - "M0002", - "M0003", - "M0004" + "M0002" ], "submissionMethods": [ - "claims", "registry" ], "measureSets": [ - "cardiology", - "certifiedNurseMidwife", - "clinicalSocialWork", - "familyMedicine", - "gastroenterology", - "generalSurgery", - "geriatrics", - "hospitalists", - "internalMedicine", - "nephrology", - "neurology", - "obstetricsGynecology", - "oncology", - "orthopedicSurgery", - "otolaryngology", - "physicalMedicine", - "preventiveMedicine", - "pulmonology", - "rheumatology", - "skilledNursingFacility", - "thoracicSurgery", - "urology", - "vascularSurgery" + "nephrology" ], "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_047_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_047_MIPSCQM.pdf" + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_482_MIPSCQM.pdf" } }, { - "title": "Preventive Care and Screening: Influenza Immunization", - "eMeasureId": "CMS147v12", + "title": "Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", + "eMeasureId": null, "nqfEMeasureId": null, - "nqfId": "0041", - "measureId": "110", - "description": "Percentage of patients aged 6 months and older seen for a visit during the measurement period who received an influenza immunization OR who reported previous receipt of an influenza immunization.", + "nqfId": "1662", + "measureId": "489", + "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.", "measureType": "process", "isHighPriority": false, - "primarySteward": "National Committee for Quality Assurance", - "firstPerformanceYear": 2017, + "primarySteward": "Renal Physicians Association", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isInverse": false, "category": "quality", @@ -12346,272 +15461,342 @@ "clinicalGuidelineChanged": [], "metricType": "singlePerformanceRate", "allowedPrograms": [ + "mips", + "pcf", "M0002" ], "submissionMethods": [ - "claims", - "electronicHealthRecord", - "cmsWebInterface", "registry" ], - "measureSets": [], + "measureSets": [ + "geriatrics", + "nephrology" + ], "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_110_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_110_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms147v12" + "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_489_MIPSCQM.pdf" } + } + ], + "iaMeasures": [ + { + "category": "ia", + "title": "Promote Use of Patient-Reported Outcome Tools", + "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", + "measureId": "IA_AHE_3", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "achievingHealthEquity", + "allowedPrograms": [ + "G0053", + "G0056", + "G0058", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Engagement of patients through implementation of improvements in patient portal", + "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", + "measureId": "IA_BE_4", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0053", + "G0054", + "G0056", + "G0057", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", + "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", + "measureId": "IA_BE_6", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002" + ] + }, + { + "category": "ia", + "title": "Engage Patients and Families to Guide Improvement in the System of Care", + "description": "Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.", + "measureId": "IA_BE_14", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "M0002" + ] + }, + { + "category": "ia", + "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", + "description": "Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.", + "measureId": "IA_BE_15", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0053", + "G0055", + "M0001", + "M0002" + ] + }, + { + "category": "ia", + "title": "Promote Self-management in Usual Care", + "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", + "measureId": "IA_BE_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0056", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of improvements that contribute to more timely communication of test results", + "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", + "measureId": "IA_CC_2", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "G0054", + "G0056", + "G0057", + "G0059", + "M0005", + "M0002" + ] }, { - "title": "Pneumococcal Vaccination Status for Older Adults", - "eMeasureId": "CMS127v11", - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "111", - "description": "Percentage of patients 66 years of age and older who have received a pneumococcal vaccine.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "National Committee for Quality Assurance", + "category": "ia", + "title": "Practice Improvements to Align with OpenNotes Principles", + "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", + "measureId": "IA_CC_13", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "weight": "medium", + "subcategoryId": "careCoordination", "allowedPrograms": [ - "G0053", + "G0054", + "G0056", + "G0058", + "M0005", "M0002" - ], - "submissionMethods": [ - "claims", - "electronicHealthRecord", - "registry" - ], - "measureSets": [], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_111_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_111_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms127v11" - } + ] }, { - "title": "Documentation of Current Medications in the Medical Record", - "eMeasureId": "CMS68v12", - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "130", - "description": "Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.", - "measureType": "process", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", + "category": "ia", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "weight": null, + "subcategoryId": null, "allowedPrograms": [ - "mips", - "pcf", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", "M0002", - "M0003" - ], - "submissionMethods": [ - "registry", - "electronicHealthRecord" - ], - "measureSets": [ - "allergyImmunology", - "audiology", - "cardiology", - "certifiedNurseMidwife", - "clinicalSocialWork", - "dermatology", - "endocrinology", - "familyMedicine", - "gastroenterology", - "generalSurgery", - "geriatrics", - "hospitalists", - "infectiousDisease", - "internalMedicine", - "mentalBehavioralHealth", - "nephrology", - "neurology", - "neurosurgical", - "nutritionDietician", - "obstetricsGynecology", - "oncology", - "ophthalmology", - "orthopedicSurgery", - "otolaryngology", - "physicalMedicine", - "physicalTherapyOccupationalTherapy", - "plasticSurgery", - "preventiveMedicine", - "pulmonology", - "rheumatology", - "speechLanguagePathology", - "thoracicSurgery", - "urgentCare", - "urology", - "vascularSurgery" - ], - "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_130_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms068v12" - } + "M0003", + "M0004" + ] }, { - "title": "Controlling High Blood Pressure", - "eMeasureId": "CMS165v11", - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "236", - "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", - "measureType": "intermediateOutcome", - "isHighPriority": true, - "primarySteward": "National Committee for Quality Assurance", + "category": "ia", + "title": "Regular review practices in place on targeted patient population needs", + "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", + "measureId": "IA_PM_11", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "weight": "medium", + "subcategoryId": "populationManagement", "allowedPrograms": [ - "mips", - "pcf", - "app1", - "G0054", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", + "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", + "measureId": "IA_PM_14", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "G0055", "G0056", + "M0001", "M0002" - ], - "submissionMethods": [ - "claims", - "electronicHealthRecord", - "cmsWebInterface", - "registry" - ], - "measureSets": [ - "cardiology", - "endocrinology", - "familyMedicine", - "internalMedicine", - "obstetricsGynecology", - "pulmonology", - "rheumatology", - "vascularSurgery" - ], - "measureSpecification": { - "claims": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2023_Measure_236_MedicarePartBClaims.pdf", - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_236_MIPSCQM.pdf", - "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2023/cms165v11" - } + ] }, { - "title": "Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": null, - "measureId": "482", - "description": "Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.", - "measureType": "intermediateOutcome", - "isHighPriority": true, - "primarySteward": "Centers for Medicare & Medicaid Services", - "firstPerformanceYear": 2022, + "category": "ia", + "title": "Implementation of medication management practice improvements", + "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", + "measureId": "IA_PM_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": true, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", + "weight": "medium", + "subcategoryId": "populationManagement", "allowedPrograms": [ - "mips", - "pcf", + "G0053", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Use of decision support and standardized treatment protocols", + "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", + "measureId": "IA_PSPA_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "G0059", + "M0001", "M0002" - ], + ] + } + ], + "costMeasures": [ + { + "category": "cost", + "title": "Acute Kidney Injury Requiring New Inpatient Dialysis", + "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive their first inpatient dialysis service for acute kidney injury during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", + "measureId": "COST_AKID_1", + "metricType": "costScore", + "firstPerformanceYear": 2020, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": null, "submissionMethods": [ - "registry" - ], - "measureSets": [ - "nephrology" + "administrativeClaims" ], "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_482_MIPSCQM.pdf" - } + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-aki-new-hd.pdf" + }, + "allowedPrograms": [ + "M0002" + ] }, { - "title": "Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", - "eMeasureId": null, - "nqfEMeasureId": null, - "nqfId": "1662", - "measureId": "489", - "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.", - "measureType": "process", - "isHighPriority": false, - "primarySteward": "Renal Physicians Association", - "firstPerformanceYear": 2023, + "category": "cost", + "title": "Total Per Capita Cost (TPCC)", + "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", + "measureId": "TPCC_1", + "metricType": "costScore", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "isInverse": false, - "category": "quality", - "isRegistryMeasure": false, - "isRiskAdjusted": false, - "icdImpacted": [], - "isClinicalGuidelineChanged": false, - "isIcdImpacted": false, - "clinicalGuidelineChanged": [], - "metricType": "singlePerformanceRate", - "allowedPrograms": [ - "mips", - "pcf", - "M0002" - ], + "isInverse": true, + "overallAlgorithm": "simpleAverage", "submissionMethods": [ - "registry" - ], - "measureSets": [ - "geriatrics", - "nephrology" + "administrativeClaims" ], "measureSpecification": { - "registry": "http://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_489_MIPSCQM.pdf" - } + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" + }, + "allowedPrograms": [ + "G0053", + "G0055", + "G0056", + "M0001", + "M0005", + "M0002" + ] } ], - "iaMeasures": [ + "foundationPiMeasures": [ { - "category": "ia", - "title": "Promote Use of Patient-Reported Outcome Tools", - "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", - "measureId": "IA_AHE_3", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "achievingHealthEquity", + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", "G0056", + "G0057", "G0058", + "G0059", + "M0001", "M0005", "M0002", "M0003", @@ -12619,20 +15804,36 @@ ] }, { - "category": "ia", - "title": "Engagement of patients through implementation of improvements in patient portal", - "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", - "measureId": "IA_BE_4", + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2019, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], "allowedPrograms": [ + "app1", "G0053", "G0054", + "G0055", "G0056", "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -12641,120 +15842,174 @@ ] }, { - "category": "ia", - "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", - "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", - "measureId": "IA_BE_6", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "beneficiaryEngagement", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", "G0057", "G0058", "G0059", "M0001", "M0005", - "M0002" - ] - }, - { - "category": "ia", - "title": "Engage Patients and Families to Guide Improvement in the System of Care", - "description": "Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.", - "measureId": "IA_BE_14", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "beneficiaryEngagement", - "allowedPrograms": [ - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", - "description": "Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.", - "measureId": "IA_BE_15", - "metricType": "boolean", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", "G0055", - "M0001", - "M0002" - ] - }, - { - "category": "ia", - "title": "Promote Self-management in Usual Care", - "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", - "measureId": "IA_BE_16", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "beneficiaryEngagement", - "allowedPrograms": [ "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Implementation of improvements that contribute to more timely communication of test results", - "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.", - "measureId": "IA_CC_2", + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", "G0054", + "G0055", "G0056", "G0057", + "G0058", "G0059", + "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Practice Improvements to Align with OpenNotes Principles", - "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", - "measureId": "IA_CC_13", + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "G0053", "G0054", + "G0055", "G0056", + "G0057", "G0058", + "G0059", + "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", "G0054", "G0055", @@ -12770,16 +16025,37 @@ ] }, { - "category": "ia", - "title": "Regular review practices in place on targeted patient population needs", - "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", - "measureId": "IA_PM_11", + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", "M0005", "M0002", "M0003", @@ -12787,34 +16063,32 @@ ] }, { - "category": "ia", - "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", - "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", - "measureId": "IA_PM_14", + "category": "pi", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", "G0055", "G0056", - "M0001", - "M0002" - ] - }, - { - "category": "ia", - "title": "Implementation of medication management practice improvements", - "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", - "measureId": "IA_PM_16", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", - "allowedPrograms": [ - "G0053", + "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -12823,90 +16097,61 @@ ] }, { - "category": "ia", - "title": "Use of decision support and standardized treatment protocols", - "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.", - "measureId": "IA_PSPA_16", + "category": "pi", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "G0059", - "M0001", - "M0002" - ] - } - ], - "costMeasures": [ - { - "category": "cost", - "title": "Acute Kidney Injury Requiring New Inpatient Dialysis", - "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive their first inpatient dialysis service for acute kidney injury during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", - "measureId": "COST_AKID_1", - "metricType": "costScore", - "firstPerformanceYear": 2020, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": null, - "submissionMethods": [ - "administrativeClaims" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-08-mif-ebcm-aki-new-hd.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, - "allowedPrograms": [ - "M0002" - ] - }, - { - "category": "cost", - "title": "Total Per Capita Cost (TPCC)", - "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", - "measureId": "TPCC_1", - "metricType": "costScore", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" ], - "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-tpcc.pdf" - }, "allowedPrograms": [ + "app1", "G0053", + "G0054", "G0055", "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", - "M0002" + "M0002", + "M0003", + "M0004" ] - } - ], - "foundationPiMeasures": [ + }, { "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", - "isRequired": true, - "metricType": "proportion", + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVPP_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -12925,26 +16170,22 @@ }, { "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2019, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -12963,27 +16204,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -13002,27 +16238,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVITC_2" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -13041,26 +16272,21 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13077,22 +16303,18 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -13112,24 +16334,22 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2017, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13146,28 +16366,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13184,24 +16398,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13218,28 +16430,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13256,24 +16462,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13290,24 +16494,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13324,24 +16526,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13358,24 +16558,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -13392,18 +16590,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -13423,18 +16622,19 @@ }, { "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -14019,115 +17219,432 @@ ] }, { - "category": "ia", - "title": "Financial Navigation Program", - "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", - "measureId": "IA_BE_24", + "category": "ia", + "title": "Financial Navigation Program", + "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", + "measureId": "IA_BE_24", + "metricType": "boolean", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0054", + "G0055", + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Depression screening", + "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", + "measureId": "IA_BMH_4", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth", + "allowedPrograms": [ + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Electronic Health Record Enhancements for BH data capture", + "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", + "measureId": "IA_BMH_8", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth", + "allowedPrograms": [ + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", + "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", + "measureId": "IA_CC_1", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", + "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", + "measureId": "IA_EPA_1", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "expandedPracticeAccess", + "allowedPrograms": [ + "G0053", + "G0056", + "G0059", + "M0001", + "M0005", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Use of telehealth services that expand practice access", + "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", + "measureId": "IA_EPA_2", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "expandedPracticeAccess", + "allowedPrograms": [ + "G0053", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": null, + "subcategoryId": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Regular review practices in place on targeted patient population needs", + "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", + "measureId": "IA_PM_11", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of medication management practice improvements", + "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", + "measureId": "IA_PM_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "G0053", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Advance Care Planning", + "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", + "measureId": "IA_PM_21", + "metricType": "boolean", + "firstPerformanceYear": 2018, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "populationManagement", + "allowedPrograms": [ + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of fall screening and assessment programs", + "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", + "measureId": "IA_PSPA_21", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "patientSafetyAndPracticeAssessment", + "allowedPrograms": [ + "M0003", + "M0004" + ] + } + ], + "costMeasures": [ + { + "category": "cost", + "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", + "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", + "measureId": "MSPB_1", + "metricType": "costScore", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "isInverse": true, + "overallAlgorithm": "simpleAverage", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" + }, + "allowedPrograms": [ + "G0057", + "G0059", + "M0003", + "M0004" + ] + } + ], + "foundationPiMeasures": [ + { + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", "G0054", "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Depression screening", - "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", - "measureId": "IA_BMH_4", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "behavioralAndMentalHealth", - "allowedPrograms": [ - "M0003", - "M0004" - ] - }, - { - "category": "ia", - "title": "Electronic Health Record Enhancements for BH data capture", - "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", - "measureId": "IA_BMH_8", - "metricType": "boolean", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "behavioralAndMentalHealth", - "allowedPrograms": [ - "M0003", - "M0004" - ] - }, - { - "category": "ia", - "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", - "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", - "measureId": "IA_CC_1", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", - "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", - "measureId": "IA_EPA_1", - "metricType": "boolean", - "firstPerformanceYear": 2017, + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", "G0056", + "G0057", + "G0058", "G0059", "M0001", "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Use of telehealth services that expand practice access", - "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", - "measureId": "IA_EPA_2", + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", "G0054", @@ -14144,16 +17661,33 @@ ] }, { - "category": "ia", - "title": "Regular review practices in place on targeted patient population needs", - "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", - "measureId": "IA_PM_11", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", "M0005", "M0002", "M0003", @@ -14161,17 +17695,36 @@ ] }, { - "category": "ia", - "title": "Implementation of medication management practice improvements", - "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", - "measureId": "IA_PM_16", + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -14180,82 +17733,60 @@ ] }, { - "category": "ia", - "title": "Advance Care Planning", - "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", - "measureId": "IA_PM_21", - "metricType": "boolean", - "firstPerformanceYear": 2018, - "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", - "allowedPrograms": [ - "M0001", - "M0003", - "M0004" - ] - }, - { - "category": "ia", - "title": "Implementation of fall screening and assessment programs", - "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", - "measureId": "IA_PSPA_21", + "category": "pi", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "M0003", - "M0004" - ] - } - ], - "costMeasures": [ - { - "category": "cost", - "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", - "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", - "measureId": "MSPB_1", - "metricType": "costScore", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", "G0057", + "G0058", "G0059", + "M0001", + "M0005", + "M0002", "M0003", "M0004" ] - } - ], - "foundationPiMeasures": [ + }, { "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, "measureSets": [], "exclusion": [ - "PI_LVPP_1" + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "app1", @@ -14275,26 +17806,22 @@ }, { "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2019, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -14313,27 +17840,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", - "isRequired": true, - "metricType": "proportion", + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -14352,27 +17874,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVITC_2" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -14391,21 +17908,19 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], "exclusion": null, @@ -14427,22 +17942,18 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -14462,24 +17973,21 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14496,28 +18004,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PROD" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14534,24 +18036,54 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, + "metricType": "boolean", + "firstPerformanceYear": 2023, + "lastPerformanceYear": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_1_PRE" + ], + "measureSets": [], + "exclusion": null, + "allowedPrograms": [ + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14568,28 +18100,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14606,24 +18132,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14640,24 +18164,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14674,24 +18196,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14708,24 +18228,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -14742,18 +18260,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -14773,18 +18292,19 @@ }, { "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -15440,39 +18960,181 @@ "iaMeasures": [ { "category": "ia", - "title": "Promote Use of Patient-Reported Outcome Tools", - "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", - "measureId": "IA_AHE_3", + "title": "Promote Use of Patient-Reported Outcome Tools", + "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", + "measureId": "IA_AHE_3", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "high", + "subcategoryId": "achievingHealthEquity", + "allowedPrograms": [ + "G0053", + "G0056", + "G0058", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Engagement of patients through implementation of improvements in patient portal", + "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", + "measureId": "IA_BE_4", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0053", + "G0054", + "G0056", + "G0057", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Promote Self-management in Usual Care", + "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", + "measureId": "IA_BE_16", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0056", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Financial Navigation Program", + "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", + "measureId": "IA_BE_24", + "metricType": "boolean", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "beneficiaryEngagement", + "allowedPrograms": [ + "G0054", + "G0055", + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Depression screening", + "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", + "measureId": "IA_BMH_4", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth", + "allowedPrograms": [ + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Electronic Health Record Enhancements for BH data capture", + "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", + "measureId": "IA_BMH_8", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "behavioralAndMentalHealth", + "allowedPrograms": [ + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", + "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", + "measureId": "IA_CC_1", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": "medium", + "subcategoryId": "careCoordination", + "allowedPrograms": [ + "M0001", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", + "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", + "measureId": "IA_EPA_1", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "high", - "subcategoryId": "achievingHealthEquity", + "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "G0053", "G0056", - "G0058", + "G0059", + "M0001", "M0005", - "M0002", "M0003", "M0004" ] }, { "category": "ia", - "title": "Engagement of patients through implementation of improvements in patient portal", - "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.", - "measureId": "IA_BE_4", + "title": "Use of telehealth services that expand practice access", + "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", + "measureId": "IA_EPA_2", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "subcategoryId": "expandedPracticeAccess", + "allowedPrograms": [ + "G0053", + "M0003", + "M0004" + ] + }, + { + "category": "ia", + "title": "Electronic submission of Patient Centered Medical Home accreditation", + "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", + "measureId": "IA_PCMH", + "metricType": "boolean", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "weight": null, + "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", + "G0055", "G0056", "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -15482,16 +19144,16 @@ }, { "category": "ia", - "title": "Promote Self-management in Usual Care", - "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", - "measureId": "IA_BE_16", + "title": "Regular review practices in place on targeted patient population needs", + "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", + "measureId": "IA_PM_11", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "subcategoryId": "populationManagement", "allowedPrograms": [ - "G0056", + "M0005", "M0002", "M0003", "M0004" @@ -15499,114 +19161,289 @@ }, { "category": "ia", - "title": "Financial Navigation Program", - "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", - "measureId": "IA_BE_24", + "title": "Implementation of medication management practice improvements", + "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", + "measureId": "IA_PM_16", "metricType": "boolean", - "firstPerformanceYear": 2019, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "beneficiaryEngagement", + "subcategoryId": "populationManagement", "allowedPrograms": [ - "G0054", - "G0055", + "G0053", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { "category": "ia", - "title": "Depression screening", - "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", - "measureId": "IA_BMH_4", + "title": "Advance Care Planning", + "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", + "measureId": "IA_PM_21", "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2018, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "behavioralAndMentalHealth", + "subcategoryId": "populationManagement", "allowedPrograms": [ + "M0001", "M0003", "M0004" ] }, { "category": "ia", - "title": "Electronic Health Record Enhancements for BH data capture", - "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).", - "measureId": "IA_BMH_8", + "title": "Implementation of fall screening and assessment programs", + "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", + "measureId": "IA_PSPA_21", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "weight": "medium", - "subcategoryId": "behavioralAndMentalHealth", + "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "M0003", "M0004" ] - }, + } + ], + "costMeasures": [ { - "category": "ia", - "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop", - "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.", - "measureId": "IA_CC_1", - "metricType": "boolean", + "category": "cost", + "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", + "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", + "measureId": "MSPB_1", + "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "careCoordination", + "isInverse": true, + "overallAlgorithm": "simpleAverage", + "submissionMethods": [ + "administrativeClaims" + ], + "measureSpecification": { + "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" + }, + "allowedPrograms": [ + "G0057", + "G0059", + "M0003", + "M0004" + ] + } + ], + "foundationPiMeasures": [ + { + "category": "pi", + "measureId": "PI_EP_1", + "title": "e-Prescribing", + "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2017, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVPP_1" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record", - "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.", - "measureId": "IA_EPA_1", + "category": "pi", + "measureId": "PI_EP_2", + "title": "Query of the Prescription Drug Monitoring Program (PDMP)", + "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", + "isRequired": true, "metricType": "boolean", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "electronicPrescribing", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_EP_2_EX_1", + "PI_EP_2_EX_2", + "PI_EP_2_EX_3" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_1", + "title": "Support Electronic Referral Loops By Sending Health Information", + "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "high", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVOTC_1" + ], + "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", + "M0003", + "M0004" + ] + }, + { + "category": "pi", + "measureId": "PI_HIE_4", + "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", + "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "isRequired": true, + "metricType": "proportion", + "firstPerformanceYear": 2019, + "lastPerformanceYear": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5", + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_LVITC_2" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", "G0056", + "G0057", + "G0058", "G0059", "M0001", "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Use of telehealth services that expand practice access", - "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", - "measureId": "IA_EPA_2", + "category": "pi", + "measureId": "PI_HIE_5", + "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", + "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2021, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "expandedPracticeAccess", + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_6" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Electronic submission of Patient Centered Medical Home accreditation", - "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", - "measureId": "IA_PCMH", + "category": "pi", + "measureId": "PI_HIE_6", + "title": "Enabling Exchange Under TEFCA", + "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "weight": null, - "subcategoryId": null, + "objective": "healthInformationExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_HIE_5" + ], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "G0053", "G0054", @@ -15623,16 +19460,33 @@ ] }, { - "category": "ia", - "title": "Regular review practices in place on targeted patient population needs", - "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", - "measureId": "IA_PM_11", - "metricType": "boolean", + "category": "pi", + "measureId": "PI_PEA_1", + "title": "Provide Patients Electronic Access to Their Health Information", + "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "isRequired": true, + "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "providerToPatientExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", + "M0001", "M0005", "M0002", "M0003", @@ -15640,17 +19494,36 @@ ] }, { - "category": "ia", - "title": "Implementation of medication management practice improvements", - "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", - "measureId": "IA_PM_16", + "category": "pi", + "measureId": "PI_PHCDRR_1", + "title": "Immunization Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_1_EX_1", + "PI_PHCDRR_1_EX_2", + "PI_PHCDRR_1_EX_3" + ], "allowedPrograms": [ + "app1", "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", "M0005", "M0002", @@ -15659,83 +19532,95 @@ ] }, { - "category": "ia", - "title": "Advance Care Planning", - "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", - "measureId": "IA_PM_21", + "category": "pi", + "measureId": "PI_PHCDRR_2", + "title": "Syndromic Surveillance Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2018, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "populationManagement", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [], + "measureSpecification": { + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", + "G0057", + "G0058", + "G0059", "M0001", + "M0005", + "M0002", "M0003", "M0004" ] }, { - "category": "ia", - "title": "Implementation of fall screening and assessment programs", - "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", - "measureId": "IA_PSPA_21", + "category": "pi", + "measureId": "PI_PHCDRR_3", + "title": "Electronic Case Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "isRequired": true, "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "weight": "medium", - "subcategoryId": "patientSafetyAndPracticeAssessment", - "allowedPrograms": [ - "M0003", - "M0004" - ] - } - ], - "costMeasures": [ - { - "category": "cost", - "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", - "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", - "measureId": "MSPB_1", - "metricType": "costScore", - "firstPerformanceYear": 2017, - "lastPerformanceYear": null, - "isInverse": true, - "overallAlgorithm": "simpleAverage", - "submissionMethods": [ - "administrativeClaims" - ], + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": false, + "reportingCategory": "required", + "substitutes": [], "measureSpecification": { - "default": "https://qpp.cms.gov/docs/cost_specifications/2022-12-02-mif-mspb-clinician.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" }, + "measureSets": [], + "exclusion": [ + "PI_PHCDRR_3_EX_1", + "PI_PHCDRR_3_EX_2", + "PI_PHCDRR_3_EX_3" + ], "allowedPrograms": [ + "app1", + "G0053", + "G0054", + "G0055", + "G0056", "G0057", + "G0058", "G0059", + "M0001", + "M0005", + "M0002", "M0003", "M0004" ] - } - ], - "foundationPiMeasures": [ + }, { "category": "pi", - "measureId": "PI_EP_1", - "title": "e-Prescribing", - "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", - "isRequired": true, - "metricType": "proportion", + "measureId": "PI_PHCDRR_4", + "title": "Public Health Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", + "isRequired": false, + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEPrescribing.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVPP_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -15754,26 +19639,22 @@ }, { "category": "pi", - "measureId": "PI_EP_2", - "title": "Query of the Prescription Drug Monitoring Program (PDMP)", - "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", - "isRequired": true, + "measureId": "PI_PHCDRR_5", + "title": "Clinical Data Registry Reporting", + "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", + "isRequired": false, "metricType": "boolean", - "firstPerformanceYear": 2019, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "electronicPrescribing", - "isBonus": false, - "reportingCategory": "required", + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresQueryofPrescriptionDrugMonitoringProgram.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_EP_2_EX_1", - "PI_EP_2_EX_2", - "PI_EP_2_EX_3" - ], + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" + }, + "measureSets": [], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -15792,27 +19673,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_1", - "title": "Support Electronic Referral Loops By Sending Health Information", - "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", + "measureId": "PI_PPHI_1", + "title": "Security Risk Analysis", + "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", "isRequired": true, - "metricType": "proportion", + "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsbySendingHealthInfo.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVOTC_1" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -15831,27 +19707,22 @@ }, { "category": "pi", - "measureId": "PI_HIE_4", - "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", - "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", + "measureId": "PI_PPHI_2", + "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", + "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2019, + "metricType": "boolean", + "firstPerformanceYear": 2022, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5", - "PI_HIE_6" - ], + "substitutes": [], "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSupportElectronicReferralLoopsReceivingandReconcilling.pdf" + "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" }, "measureSets": [], - "exclusion": [ - "PI_LVITC_2" - ], + "exclusion": null, "allowedPrograms": [ "app1", "G0053", @@ -15870,26 +19741,21 @@ }, { "category": "pi", - "measureId": "PI_HIE_5", - "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", - "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", + "measureId": "PI_INFBLO_1", + "title": "Actions to Limit or Restrict the Compatibility of CEHRT", + "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2021, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_6" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov//docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresHIEBi-DirectionalExchange.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -15906,22 +19772,18 @@ }, { "category": "pi", - "measureId": "PI_HIE_6", - "title": "Enabling Exchange Under TEFCA", - "description": "Provide eligible clinicians with the opportunity to earn credit for the Health Information exchange objective if they: are a signatory to a “Framework Agreement” as that term is defined in the Common Agreement; enable secure, bi-directional exchange of information to occur for all unique patients of eligible clinicians, and all unique patient records stored or maintained in the EHR; and use the functions of CEHRT to support bidirectional exchange.", + "measureId": "PI_ONCDIR_1", + "title": "ONC Direct Review Attestation", + "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2023, + "firstPerformanceYear": 2017, "lastPerformanceYear": null, - "objective": "healthInformationExchange", + "objective": "attestation", "isBonus": false, "reportingCategory": "required", - "substitutes": [ - "PI_HIE_5" - ], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresEnablingExchangeUnderTEFCA.pdf" - }, + "substitutes": [], + "measureSpecification": null, "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -15941,24 +19803,22 @@ }, { "category": "pi", - "measureId": "PI_PEA_1", - "title": "Provide Patients Electronic Access to Their Health Information", - "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", + "measureId": "PI_PHCDRR_1_PRE", + "title": "Immunization Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, - "metricType": "proportion", - "firstPerformanceYear": 2017, + "metricType": "boolean", + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "providerToPatientExchange", + "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresProvidePatientsElectronicAccess.pdf" - }, + "substitutes": [ + "PI_PHCDRR_1_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -15975,28 +19835,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_1", - "title": "Immunization Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).", + "measureId": "PI_PHCDRR_1_PROD", + "title": "Immunization Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresImmunizationRegistryReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_1_EX_1", - "PI_PHCDRR_1_EX_2", - "PI_PHCDRR_1_EX_3" + "substitutes": [ + "PI_PHCDRR_1_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16013,24 +19867,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_2", - "title": "Syndromic Surveillance Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.", - "isRequired": false, + "measureId": "PI_PHCDRR_2_PRE", + "title": "Syndromic Surveillance Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSyndromicSurveillanceReporting.pdf" - }, + "substitutes": [ + "PI_PHCDRR_2_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16047,28 +19899,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_3", - "title": "Electronic Case Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.", + "measureId": "PI_PHCDRR_2_PROD", + "title": "Syndromic Surveillance Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresElectronicCaseReporting.pdf" - }, - "measureSets": [], - "exclusion": [ - "PI_PHCDRR_3_EX_1", - "PI_PHCDRR_3_EX_2", - "PI_PHCDRR_3_EX_3" + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_2_PRE" ], + "measureSets": [], + "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16085,24 +19931,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_4", - "title": "Public Health Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PRE", + "title": "Electronic Case Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresPublicHealthRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16119,24 +19963,22 @@ }, { "category": "pi", - "measureId": "PI_PHCDRR_5", - "title": "Clinical Data Registry Reporting", - "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", - "isRequired": false, + "measureId": "PI_PHCDRR_3_PROD", + "title": "Electronic Case Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", + "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, "objective": "publicHealthAndClinicalDataExchange", - "isBonus": true, - "reportingCategory": "bonus", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresClinicalDataRegistryReporting.pdf" - }, + "isBonus": false, + "reportingCategory": "required", + "substitutes": [ + "PI_PHCDRR_3_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16153,24 +19995,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_1", - "title": "Security Risk Analysis", - "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.", + "measureId": "PI_PHCDRR_4_PRE", + "title": "Public Health Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSecurityRiskAnalysis.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16187,24 +20027,22 @@ }, { "category": "pi", - "measureId": "PI_PPHI_2", - "title": "High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides", - "description": "Conduct an annual assessment of the High Priority Practices Guide SAFER Guides.", + "measureId": "PI_PHCDRR_4_PROD", + "title": "Public Health Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2022, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "protectPatientHealthInformation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": { - "default": "http://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2023MIPSPIMeasuresSafetyAssuranceFactorsforEHRResilience.pdf" - }, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_4_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ - "app1", "G0053", "G0054", "G0055", @@ -16221,18 +20059,19 @@ }, { "category": "pi", - "measureId": "PI_INFBLO_1", - "title": "Actions to Limit or Restrict the Compatibility of CEHRT", - "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", + "measureId": "PI_PHCDRR_5_PRE", + "title": "Clinical Data Registry Reporting Active Engagement Level 1", + "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PROD" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ @@ -16252,18 +20091,19 @@ }, { "category": "pi", - "measureId": "PI_ONCDIR_1", - "title": "ONC Direct Review Attestation", - "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", + "measureId": "PI_PHCDRR_5_PROD", + "title": "Clinical Data Registry Reporting Active Engagement Level 2", + "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "isRequired": true, "metricType": "boolean", - "firstPerformanceYear": 2017, + "firstPerformanceYear": 2023, "lastPerformanceYear": null, - "objective": "attestation", - "isBonus": false, - "reportingCategory": "required", - "substitutes": [], - "measureSpecification": null, + "objective": "publicHealthAndClinicalDataExchange", + "isBonus": true, + "reportingCategory": "bonus", + "substitutes": [ + "PI_PHCDRR_5_PRE" + ], "measureSets": [], "exclusion": null, "allowedPrograms": [ diff --git a/mvp/2023/mvp.json b/mvp/2023/mvp.json index 56db9fce..5bdf2189 100644 --- a/mvp/2023/mvp.json +++ b/mvp/2023/mvp.json @@ -51,7 +51,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -114,7 +124,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -185,7 +205,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -256,7 +286,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -317,7 +357,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -378,7 +428,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -441,7 +501,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -510,7 +580,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -584,7 +664,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -649,7 +739,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -716,7 +816,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479", @@ -786,7 +896,17 @@ "PI_PPHI_1", "PI_PPHI_2", "PI_INFBLO_1", - "PI_ONCDIR_1" + "PI_ONCDIR_1", + "PI_PHCDRR_1_PRE", + "PI_PHCDRR_1_PROD", + "PI_PHCDRR_2_PRE", + "PI_PHCDRR_2_PROD", + "PI_PHCDRR_3_PRE", + "PI_PHCDRR_3_PROD", + "PI_PHCDRR_4_PRE", + "PI_PHCDRR_4_PROD", + "PI_PHCDRR_5_PRE", + "PI_PHCDRR_5_PROD" ], "foundationQualityMeasureIds": [ "479",