Eligible Clinician Supported Measures

2020

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MIPS and Medicaid CQMs
MIPS Promoting Interoperability
Medicaid Promoting Interoperability
Improvement Activities Measures

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MIPS and Medicaid Clinical Quality Measures

Measure Description
CMS002  Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 
CMS022  Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
CMS050  Closing the referral loop: receipt of specialist report
CMS056 Functional Status Assessment for Hip Replacement
CMS066 Functional Status Assessment for Knee Replacement
CMS068 Documentation of Current Medications in the Medical Record
CMS069 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up - 18-64
CMS074 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists - 0-20
CMS075 Children Who Have Dental Decay or Cavities
CMS082 Maternal Depression Screening
CMS117 Childhood Immunization Status
CMS122 Diabetes: Hemoglobin A1c Poor Control
CMS124 Cervical Cancer Screening
CMS125 Breast Cancer Screening
CMS127 Pneumonia Vaccination Status for Older Adults
CMS128 Anti-depressant Medication Management
CMS129 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
CMS130 Colorectal Cancer Screening
CMS131 Diabetes: Eye Exam
CMS133 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
CMS134 Diabetes: Urine Protein Screening
CMS135 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS135-B Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS136-A ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication - Visit within 30 days
CMS136-B ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication - Visit with 2+ followups
CMS137 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
CMS138-A Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - 18 years and older who were screened one or more times within 24 months
CMS138-B Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - 18 years and older who were screened and identified as a tobacco user who received tobacco cessation intervention
CMS138-C Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - 18 years and older who were screened one or more times within 24 months and identified as a tobacco user who received tobacco cessation intervention
CMS139 Falls: Screening for Future Fall Risk
CMS142 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
CMS143 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
CMS144-A Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS144-B Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
CMS145-A Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) - LVSD
CMS145-B Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) - prior MI
CMS146 Appropriate Testing for Children with Pharyngitis
CMS147 Preventive Care and Screening: Influenza Immunization
CMS149 DementiaCognitive - Dementia: Cognitive Assessment
CMS153 Chlamydia Screening for Women - 16-24
CMS154 Appropriate Treatment for Children with Upper Respiratory Infection (URI)
CMS155 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
CMS156 Use of High-Risk Medications in the Elderly
CMS157-A Oncology: Medical and Radiation – Face to Face Encounter with Ongoing Chemotherapy
CMS157-B Oncology: Medical and Radiation – Radiation Treatment with Cancer Diagnosis
CMS159 Depression Remission at Twelve Months
CMS161 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
CMS165 Controlling High Blood Pressure
CMS177 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
CMS347-A Statin Therapy for the Prevention and Treatment of Cardiovascular Disease - Patients aged >= 21 years with clinical ASCVD diagnosis
CMS347-B Statin Therapy for the Prevention and Treatment of Cardiovascular Disease - Patients aged >= 21 years laboratory result of LDL-C >=190 mg/dL
CMS347-C Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
CMS645

Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy

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MIPS Promoting Interoperability Measures

  Measure  Description
PI_EP_1 e-Prescribing Generate and transmit permissible prescriptions electronically
PI_EP_2  Query of Prescription Drug Monitoring Program (PDMP) For at least one Schedule II opioid 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, except where prohibited and in accordance with applicable law.
PI_HIE_1 Support Electronic Referral Loops by Sending Health Information Creates or electronically exchanges a SOC record for transitions of care and referrals or new patients
PI_HIE_4 Support Electronic Referral Loops by Receiving and Incorporating Health Information Perform a clinical information reconciliation (medications, allergies, problem lists) where at least one SOC was received for transitions of care, referrals, or new patients
PI_PEA_1 Provide Patients Electronic Access to Their Health Information Provide patients the ability to view online, download, and transmit their health information
PI_PHCDRR_1   Immunization Registry Actively engaged to submit Immunization data and receive forecasts from the registry or IIS
PI_PHCDRR_1_M Immunization Registry (Multiple Submissions) Actively engaged to submit Immunization data and receive forecasts from multiple registries or IIS
PI_PHCDRR_2 Syndromic Surveillance Actively engaged to submit syndromic surveillance data from an urgent care setting
PI_PHCDRR_2_M Syndromic Surveillance (Multiple Submissions) Actively engaged to submit syndromic surveillance data from an urgent care setting to multiple Public Health Agencies
PI_PHCDRR_3 Electronic Case Actively engaged to submit case reporting of reportable conditions
PI_PHCDRR_3_M Electronic Case (Multiple Submissions) Actively engaged to submit case reporting of reportable conditions to multiple Public Health Agencies
PI_PHCDRR_4 Public Health Registry Actively engaged to submit data to a Public Health Registry
PI_PHCDRR_4_M Public Health Registry (Multiple Submissions) Actively engaged to submit data to multiple Public Health Registries
PI_PHCDRR_5 Clinical Data Registry Actively engaged to submit data to a Clinical Data Registry
PI_PHCDRR_5_M Clinical Data Registry (Multiple Submissions) Actively engaged to submit data to multiple Clinical Data Registries
PI_PPHI_1 Security Risk Analysis Protect ePHI by implementing appropriate technical, administrative and physical safeguards

 

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Medicaid Promoting Interoperability Measures

Measure Description
View, Download or Transmit (VDT) Actively engage with the electronic health record made accessible by the provider
Secure Messaging Send a secure electronic message using CEHRT to the patient, or respond to a secure message sent by the patient
Patient Generated Health Data Patient generated health data or data from a nonclinical setting is incorporated into the CEHRT for unique patients discharged during the reporting period
CDS Interventions Use clinical decision support (5 interventions) to improve performance on high-priority health conditions
Drug Interaction Implement drug-drug and drug-allergy interaction checks
CPOE Medications Use computerized provider order entry (CPOE) for medication orders
CPOE Laboratory Use computerized provider order entry (CPOE) for laboratory orders
CPOE Diagnostic Imaging Use computerized provider order entry (CPOE) for diagnostic imaging orders
e-Prescribing Generate and transmit permissible prescriptions electronically
Send a Summary of Care Creates or electronically exchanges a SOC record for transitions of care and referrals or new patients
Request/Accept Summary of Care Requests or accepts an electronic SOC record for transitions of care and referrals or new patients
Clinical Information Reconciliation Perform a clinical information reconciliation (medications, allergies, problem lists) for transitions of care and referrals
Provide Patient Access Provide patients the ability to view online, download, and transmit their health information within 36 hours of hospital discharge
Patient-Specific Education Provide patient-specified educational resources
Immunization Registry Actively engaged to submit Immunization data and receive forecasts from the registry or IIS
Immunization Registry (Multiple Submissions) Actively engaged to submit Immunization data and receive forecasts from multiple registries or IIS
Syndromic Surveillance Actively engaged to submit syndromic surveillance data from an urgent care setting
Syndromic Surveillance (Multiple Submissions) Actively engaged to submit syndromic surveillance data from an urgent care setting to multiple Public Health Agencies
Electronic Case Actively engaged to submit case reporting of reportable conditions
Electronic Case (Multiple Submissions) Actively engaged to submit case reporting of reportable conditions to multiple Public Health Agencies
Public Health Registry Actively engaged to submit data to a Public Health Registry
Public Health Registry (Multiple Submissions) Actively engaged to submit data to multiple Public Health Registries
Clinical Data Registry Actively engaged to submit data to a Clinical Data Registry
Clinical Data Registry (Multiple Submissions) Actively engaged to submit data to multiple Clinical Data Registries
Security Risk Analysis Protect ePHI by implementing appropriate technical, administrative and physical safeguards

 

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Improvement Activities Measures

Activity Description
IA_AHE_1   Engagement of New Medicaid Patients and Follow-up
IA_AHE_3 Promote Use of Patient-Reported Outcome Tools
IA_AHE_5 MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
IA_AHE_6 Provide Education Opportunities for New Clinicians
IA_AHE_7 Comprehensive Eye Exams
IA_BE_1 Use of certified EHR to capture patient reported outcomes
IA_BE_12 Use evidence-based decision aids to support shared decision-making.
IA_BE_13 Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
IA_BE_14 Engage patients and families to guide improvement in the system of care.
IA_BE_15 Engagement of patients, family and caregivers in developing a plan of care
IA_BE_16 Evidenced-based techniques to promote self-management into usual care
IA_BE_17 Use of tools to assist patient self-management
IA_BE_18 Provide peer-led support for self-management.
IA_BE_19 Use group visits for common chronic conditions (e.g., diabetes).
IA_BE_20 Implementation of condition-specific chronic disease self-management support programs
IA_BE_21 Improved practices that disseminate appropriate self-management materials
IA_BE_22 Improved practices that engage patients pre-visit
IA_BE_23 Integration of patient coaching practices between visits
IA_BE_24 Financial Navigation Program
IA_BE_25 Drug Cost Transparency
IA_BE_3 Engagement with QIN-QIO to implement self-management training programs
IA_BE_4 Engagement of patients through implementation of improvements in patient portal
IA_BE_5 Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
IA_BE_6 Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
IA_BE_7 Participation in a QCDR, that promotes use of patient engagement tools.
IA_BE_8 Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
IA_BMH_1 Diabetes screening
IA_BMH_10   Completion of Collaborative Care Management Training Program
IA_BMH_2 Tobacco use
IA_BMH_4 Depression screening
IA_BMH_5 MDD prevention and treatment interventions
IA_BMH_6 Implementation of co-location PCP and MH services
IA_BMH_7 Implementation of Integrated Patient Centered Behavioral Health Model
IA_BMH_8 Electronic Health Record Enhancements for BH data capture
IA_BMH_9 Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients
IA_CC_1 Implementation of use of specialist reports back to referring clinician or group to close referral loop
IA_CC_10 Care transition documentation practice improvements
IA_CC_11 Care transition standard operational improvements
IA_CC_12 Care coordination agreements that promote improvements in patient tracking across settings
IA_CC_13 Practice improvements for bilateral exchange of patient information
IA_CC_14 Practice improvements that engage community resources to support patient health goals
IA_CC_15 PSH Care Coordination
IA_CC_16 Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients
IA_CC_17 Patient Navigator Program
IA_CC_18 Patient Navigator Program
IC_CC_19 Tracking of clinician's relationship to and responsibility for a patient by reporting MACRA patient relationship codes.
IA_CC_2 Implementation of improvements that contribute to more timely communication of test results
IA_CC_5 CMS partner in Patients Hospital Improvement Innovation Networks
IA_CC_7 Regular training in care coordination
IA_CC_8 Implementation of documentation improvements for practice/process improvements
IA_CC_9 Implementation of practices/processes for developing regular individual care plans
IA_EPA_1 Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record
IA_EPA_2 Use of telehealth services that expand practice access
IA_EPA_3 Collection and use of patient experience and satisfaction data on access
IA_EPA_4 Additional improvements in access as a result of QIN/QIO TA
IA_EPA_5 Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
IA_ERP_1 Participation on Disaster Medical Assistance Team, registered for 6 months.
IA_ERP_2 Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
IA_PCMH Patient Centered Medical Home Option
IA_PM_11 Regular review practices in place on targeted patient population needs
IA_PM_12 Population empanelment
IA_PM_13 Chronic care and preventative care management for empanelled patients
IA_PM_14 Implementation of methodologies for improvements in longitudinal care management for high risk patients
IA_PM_15 Implementation of episodic care management practice improvements
IA_PM_16 Implementation of medication management practice improvements
IA_PM_17 Participation in Population Health Research
IA_PM_18 Provide Clinical-Community Linkages
IA_PM_19 Glycemic Screening Services
IA_PM_2 Anticoagulant management improvements
IA_PM_20 Glycemic Referring Services
IA_PM_21 Advance Care Planning
IA_PM_3 RHC, IHS or FQHC quality improvement activities
IA_PM_4 Glycemic management services
IA_PM_5 Engagement of community for health status improvement
IA_PM_6 Use of toolsets or other resources to close healthcare disparities across communities
IA_PM_7 Use of QCDR for feedback reports that incorporate population health
IA_PSPA_1 Participation in an AHRQ-listed patient safety organization.
IA_PSPA_10 Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
IA_PSPA_11 Participation in CAHPS or other supplemental questionnaire
IA_PSPA_12 Participation in private payer CPIA
IA_PSPA_13 Participation in Joint Commission Evaluation Initiative
IA_PSPA_15 Implementation of antibiotic stewardship program
IA_PSPA_16 Use of decision support and standardized treatment protocols
IA_PSPA_17 Implementation of analytic capabilities to manage total cost of care for practice population
IA_PSPA_18 Measurement and improvement at the practice and panel level
IA_PSPA_19 Implementation of formal quality improvement methods, practice changes or other practice improvement processes
IA_PSPA_2 Participation in MOC Part IV
IA_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_PSPA_21 Implementation of fall screening and assessment programs
IA_PSPA_22 CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain
IA_PSPA_23 Completion of CDC Training on Antibiotic Stewardship
IA_PSPA_25 Cost Display for Laboratory and Radiographic Orders
IA_PSPA_26 Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event
IA_PSPA_27 Invasive Procedure or Surgery Anticoagulation Medication Management
IA_PSPA_28 Completion of an Accredited Safety or Quality Improvement Program
IA_PSPA_29 Consulting AUC Using Clinical Decision Support when Ordering Advanced
IA_PSPA_3 Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.
IA_PSPA_30 PCI Bleeding Campaign
IA_PSPA_31 Patient Medication Risk Education
IA_PSPA_32 Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support
IA_PSPA_4 Administration of the AHRQ Survey of Patient Safety Culture
IA_PSPA_6 Consultation of the Prescription Drug Monitoring program
IA_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements
IA_PSPA_8 Use of patient safety tools
IA_PSPA_9 Completion of the AMA STEPS Forward program

 

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