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QCDR/MIPS

Effortless MIPS Reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for MIPS reporting direct to CMS. OBERD has defined a set of measures that assist in MIPS reporting. For OBERD clients, this data is collected effortlessly in the background as part of the patient-reported workflow. 

QCDR/MIPS

10 reasons why you should choose OBERD for MIPS reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for MIPS reporting direct to CMS. OBERD has defined a set of measures that assist in MIPS reporting. For OBERD clients, this data is collected effortlessly in the background as part of the patient-reported workflow. 

1. Zero staff involvement, after set-up, for data collection and reporting to CMS
2. EMR independent data collection — no more extra “clicks”!
3. Meet 65% of the CPS with patient-reported outcomes
4. Real-time dashboard to monitor and optimize performance
5. Proactive notification of under-performing providers, to help focus your quality-improvement efforts
6. High compliance to form completion, increasing your opportunity for high CPS
7. CMS audit management on your behalf
8. A single data source to report to: CMS, AJRR, AAOS, and any other registry or organization
9. Benchmarking against over 7 million validated patient outcome forms
10. Research-validated data collection forms (license-paid by OBERD)

OBERD QCDR SUPPORTED MEASURES

All of the measures below qualify for MIPS credit. Those labeled “Non-MIPS” were developed by OBERD QCDR and approved by CMS for use in the 2018 MIPS reporting program.

OBERD allows you to collect and report patient-reported measures, independent of your EMR, to meet 65% of the MIPS Composite Performance Score. After set-up, data collection and reporting requires no staff involvement! We do it all for you, including managing CMS audits.

Sign up for our free webinar, “MIPS 2018 Updates and Strategy!”


We Guarantee You’ll Avoid a Negative Adjustment

Institutions using OBERD to collect patient-reported outcomes are off to a good start: they will avoid a negative MIPS adjustment. By using a CMS-certified Qualified Clinical Data Registry (QCDR) to collect PROMs, clients can satisfy the Clinical Practice Improvement Activities (CPIA), worth 15% of the MIPS Composite Performance Score. This “two birds one stone” benefit of patient-reported outcomes collection is a good baseline for OBERD’s MIPS strategy and gives a build-in advantage to clients who seek to collect and report Quality data to CMS using OBERD as well. 

 
  • NON-MIPS MEASURES

    All measures below were developed by OBERD QCDR and approved by CMS, and qualify for 2018 MIPS Reporting Program credit

    OBERD22 Post Stroke Outcome and Follow-Up

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the “baseline” measurement); and must have completed the same PRO between 90 and 120 days after the baseline (the “follow-up” measurement)

    NUMERATOR: Number of patients counted in the denominator for whom a follow-up score is obtained which is not less than the baseline score

    DENOMINATOR: Number of patients 18 or older, diagnosed with IS, ICH, or TIA, who received a baseline score, and who are eligible for a follow-up score during the measurement period.

    EXCLUSION: Patients unable or unwilling to provide a follow-up


    OBERD23 Health Related Quality of Life: Patient Defined Outcomes

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty, which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.

    NUMERATOR: Number of patients counted in the denominator who are asked to rate, on a scale of 0 to 10, the difficulty of performing the activity both before treatment and after treatment, and whose score has improved.

    DENOMINATOR: Number of patients 18 or older who are being treated for an impairment of the ability to perform a self-selected activity of importance to the patient’s quality of life.

    EXCLUSION: None


    OBERD25 Patient Satisfaction: Tracking Satisfaction Improvement with CG-CAHPS

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach, which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.

    NUMERATOR: Number of patients whose score did not go down between the last two assessments

    DENOMINATOR: Number of patients who have two or more CG-CAHPS scores

    EXCLUSION: None


    OBERD26 Cervical Spine Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    Type: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up patient-reported cervical spine functional assessment (eg. NDI, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up cervical spine score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up cervical spine assessment completed.

    EXCLUSION: None


    OBERD27 Foot/Ankle Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up patient-reported foot/ankle functional assessment (eg. FADI, AOFAS, FAAM, FAOS, FFI, Manchestor-Oxford Foot Pain and Disability Questionnaire, Manchestor-Oxford Foot Questionnaire or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up foot/ankle score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up foot/ankle assessment completed.

    EXCLUSION: None


    OBERD28 Hip Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up patient-reported hip functional assessment (eg Harris Hip Score, HOOS, HOOS-PS, HOOS Jr, Oxford Hip, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up hip score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up hip assessment completed.

    EXCLUSION: None

    OBERD29 Knee Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    MEASURE TYPE: Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up patient-reported knee functional assessment (eg. IKDC, KOOS, KOOS-PS, KOOS Jr. Oxford Knee, Kujala, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up knee score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up knee assessment completed.

    EXCLUSION: None

    OBERD30 Lumbar Spine Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up patient-reported lumbar spine functional assessment (eg. ODI, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up lumbar spine score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up lumbar spine assessment completed.

    EXCLUSION: None

     

    OBERD31 Quality of Life-Mental Health Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a mental component score to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.

    NUMERATOR: Number of patients whose follow-up QoL Mental Component Score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up QoL assessment completed.

    EXCLUSION: None


    OBERD32 Quality of Life – Physical Health Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.

    NUMERATOR: Number of patients whose follow-up QoL Physical Component Score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up QoL assessment completed.

    EXCLUSION: None


    OBERD33 Patient Acceptable Symptom State Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years or older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up Patient Acceptable Symptoms State (PASS) assessment to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose PASS score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one PASS assessment completed.

    Exclusion: None


    OBERD34 Upper Extremity Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the reporting period of Jan. 1, 2018 – Dec.31, 2018, a follow-up patient-reported upper extremity functional assessment (eg. PROMIS Upper Extremity, ASES, ASES – elbow, Oxford Shoulder Score, Oxford Instability Score, Penn Shoulder Score, Boston questionnaire, DASH, QuickDASH, PRWE, or equivalent CAT assessment if available) to measure improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up upper extremity score improved during the reporting period of Jan. 1, 2018- Dec. 31, 2018 in comparison to baseline or who had already reported the maximum possible score.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the reporting period of Jan. 1, 2018- Dec. 31, 2018, at least one follow-up upper extremity assessment completed.

    EXCLUSION: None

  • MIPS MEASURES

    All measures below were approved by CMS, and qualify for 2018 MIPS Reporting Program credit


    MIPS Q001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

    Measure Developer/Steward: NCQA


    MIPS Q109: Diabetes: Osteoarthritis (OA): Function and Pain Assessment

    Type: Process

    High Priority: Yes

    Quality Domain: PCCEO

    Description: Percentage of patient visits for patients aged 21 years and older with a diagnosis of Osteoarthritis (OA) with assessment for function and pain

    Measure Developer/Steward: American Academy of Orthopedic Surgeons


    MIPS Q110: Preventive Care and Screening: Influenza Immunization

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

    Measure Developer/Steward: AMA-PCPI 

     

    MIPS Q111: Pneumococcal Vaccination Status for Older Adults

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

    Measure Developer/Steward: NCQA

    MIPS Q112: Breast Cancer Screening

    Type: Process

    Quality Domain: ECC

    High Priority Measure: No

    Description: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

    Measure Developer/Steward: National Committee for Quality Assurance

    MIPS Q113: Colorectal Cancer Screening

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer

    Measure Developer/Steward: NCQA

     

    MIPS Q117: Diabetes: Eye Exam

    Type: Process

    Quality Domain: ECC 

    High Priority: No

    Description: Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q119: Diabetes: Medical Attention for Nephropathy

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy- Neurological

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months

    Measure Developer/Steward: American Podiatric Medical Association

     

    MIPS Q127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention- Evaluation of Footwear

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing

    Measure Developer/Steward: American Podiatric Medical Association

     

    MIPS Q128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter

    Normal Parameters:
    Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q130: Documentation of Current Medications in the Medical Record

    Type: Process

    Quality Domain: Patient Safety

    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. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q131: Pain Assessment and Follow-Up

    Type: Process

    Quality Domain: CCC

    High Priority: No

    Description: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

    Measure Developer/Steward: QIP/QIO

     

     

    MIPS Q143: Oncology: Medical and Radiation- Pain Intensity Quantified

    Type: Process

    Quality Domain: PCCEO

    High Priority Measure: Yes

    Description: Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

    Measure Developer/Steward: Physician Consortium for Performance Improvement

     

    MIPS Q154: Falls: Risk Assessment

    Type: Process

    Quality Domain: PS

    High Priority Measure: Yes

    Description: Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q155: Falls: Plan of Care

    Type: Process

    Quality Domain: CCC

    High Priority Measure: Yes

    Description: Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q163: Diabetes: Foot Exam

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months

    Measure Developer/Steward: American College of Rheumatology

     

    MIPS Q178: Rheumatoid Arthritis (RA): Functional Status Assessment

    Type: Process

    Quality Domain: ECC

    Description: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) whom a functional status assessment was performed at least once within 12 months

    Measure Developer/Steward: American College of Rheumatology

     

    MIPS Q179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months

    Measure Developer/Steward: American College of Rheumatology

     

    MIPS Q182: Functional Outcome Assessment

    Type: Process

    Quality Domain: CCC

    High Priority Measure: Yes

    Description: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within24 months AND who received cessation counseling intervention if identified as a tobacco user

    Measure Developer/Steward: AMA-PCPI

     

     

    MIPS Q236: Controlling High Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18 – 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period       

    Measure Developer/Steward: NCQA

     

     

    MIPS Q238: Use of High-Risk Medications in the Elderly

    Type: Process

    Quality Domain: PS

    Description: Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.

    Measure Developer/Steward: National Committee for Quality Assurance

     

     

    MIPS Q268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: All female patients of childbearing potential (12 – 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q281: Dementia: Cognitive Assessment

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period

    Measure Developer/Steward: Physician Consortium for Performance Improvement

     

    MIPS Q282: Dementia: Functional Status Assessment

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q283: Dementia: Neuropsychiatric Symptom Assessment

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q286: Dementia: Counseling Regarding Safety Concerns

    Type: Process

    Quality Domain: PS

    High Priority: Yes

    Description: Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q288: Dementia: Caregiver Education and Support

    Type: Process

    Quality Domain: CCC

    High Priority: Yes

    Description: Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

     

    MIPS Q290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment

    Type: Process

    High Priority: No

    Quality Domain: ECC

    Description: All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction in the last 12 months

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q293: Parkinson’s Disease: Rehabilitative Therapy Options

    Type: Process

    Quality Domain: CCC

    High Priority: Yes

    Description: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS 318: Falls: Screening for Future Fall Risk

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

    Measure Developer/Steward: PCPI & NCQA

     

     

    MIPS Q370: Depression Remission at Twelve Months

    Type: Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description: Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q371: Depression Utilization of the PHQ-9 Tool

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description: Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit

    Measure Developer/Steward: Minnesota Community Measurement


     

    MIPS Q373: Hypertension: Improvement in Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period

    Measure Developer/Steward: NCQA


     

    MIPS Q374: Closing the Referral Loop: Receipt of Specialist Report

    Type: Process

    Quality Domain: Communication and Care Coordination

    Description: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

    Measure Developer/Steward: AMA, LOINC®, LOINC®MIPS

     


    Q375: Functional Status Assessment for Total Knee Replacement

    Type: Process

    Quality Domain: PCCEO

    High Priority: Yes

    Description: Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q376: Functional Status Assessment for Total Hip Replacement

    Type: Process

    Quality Domain: PCCEO

    High Priority: Yes

    Description: Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

    Type: Process

    Quality Domain: PS

    High Priority: Yes

    Description: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

    Measure Developer/Steward: Physician Consortium for Performance Improvement

     

    MIPS Q398: Optional Asthma Control

    Type: Outcome

    Quality Domain: ECC

    High Priority: Yes

    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

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q402: Tobacco Use and Help with Quitting Among Adolescents

    Type: Process

    Quality Domain: Community / Population Health

    Description: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

    Measure Developer/Steward: NCQA


     

    MIPS Q411: Depression Remission at Six Months

    Type: Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description: Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q412: Documentation of Signed Opioid Treatment Agreement

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

    Measure Developer/Steward: American Academy of Neurology Institute

     

     

    MIPS Q431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

    Type: Process

    Quality Domain: Community/ Population Health

    Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

    Measure Developer/Steward: AMA-PCPI


     

    MIPS Q435: Quality of Life Assessment For Patients With Primary Headache Disorders

    Type: Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description: Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q444: Medication Management for People with Asthma

    Type: Process

    Quality Domain: ECR

    High Priority: Yes

    Description: The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period

    Measure Developer/Steward: American Academy of Neurology