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MIPS Reporting

MIPS Measures

All measures below were approved by CMS, and qualify for 2020 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 Q021: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second – Generation Cephalosporin

Type: Process

Quality Domain: Patient Safety

Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis.

Measure Developer/Steward: American Society of Plastic Surgeons

MIPS Q039: Screening for Osteoporosis for Women Aged 65-85 Years of Age

Type:Process

High Priority:No

Quality Domain: Effective Clinical Care

Description: Percentage of female patients age 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.

Measure Developer/Steward: National Committee for Quality Assurance

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 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 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 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 Q217 Functional Status Change for Patients with Knee Impairments

Type:Outcome

High Priority:Yes

Quality Domain:CCC

Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

MIPS Q218 Functional Status Change for Patients with Hip Impairments

Type: Outcome

High Priority:Yes

Quality Domain:CCC

Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

MIPS Q219 Functional Status Change for Patients with Lower Leg, Foot, or Ankle

Impairments

Type: Outcome

High Priority:Yes

Quality Domain:CCC

Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

MIPS Q220 Functional Status Change for Patients with Low Back Impairments

Type:Outcome

High Priority: Yes

Quality Domain:CCC

Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

MIPS Q221 Functional Status Change for Patients with Shoulder Impairments

Type:Outcome

High Priority:Yes

Quality Domain:CCC

Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.).The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

MIPS Q222 Functional Status Change for Patients with Elbow, Wrist, or Hand Impairments

Type:Outcome

High Priority:Yes

Quality Domain: CCC

Description:A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.) The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

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 Q317 Preventive Care and Screening: Screening for High blood Pressure and Follow-Up documented

Type:Process

High Priority:No

Quality Domain: CPH

Description:Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Measure Developer/Steward: Centers for Medicare & Medicaid Services

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 Q358 Patient-Centered Surgical Risk Assessment and communication

Type:Process

High Priority:Yes

Quality Domain: Person & Caregiver-Centered Experience & Outcome

Description:Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

Measure Developer/Steward: American College of Surgeons

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 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 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

MIPS Q459: Back Pain after Lumbar Discectomy/Laminectomy

Type: Patient Reported Outcome

Quality Domain: Person and Caregiver-Centered Experience and Outcomes

Description: For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or great on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.

Measure Developer/Steward: Minnesota Community Measurement

MIPS Q460: Back Pain after Lumbar Fusion

Type: Patient Reported Outcome

Quality Domain: Person and Caregiver-Centered Experience and Outcomes

Description: For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or great on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively. *hereafter referred to as VAS Pain

Measure Developer/Steward: Minnesota Community Measurement

MIPS Q461: Leg Pain After Lumbar Discectomy/Laminectomy

Type: Patient Reported Outcome

Quality Domain: Person and Caregiver-Centered Experience and Outcomes

Description: For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure. Leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS Pain scale at three months (6 to 20 weeks) postoperatively.

Measure Developer/Steward: Minnesota Community Measurement

MIPS Q469 Average Change in Functional Status Following Lumbar Fusion Surgery

Type:Outcome

High Priority:Yes

Quality Domain:Person & Caregiver-Centered Experience & Outcome

Description:The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2. 1a) for patients 18 years of age and older who had a lumbar fusion procedure

Measure Developer/Steward: Minnesota Community Measurement.

MIPS Q470 Average Change in Functional Status Following Total Knee Replacement

Type:Outcome

High Priority:Yes

Quality Domain:Person & Caregiver-Centered Experience & Outcome

Description:The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement

Measure Developer/Steward: Minnesota Community Measurement.

MIPS Q471 Average Change in Functioanl Status Following Lumbar Discectomy/Laminotomy Surgery

Type:Outcome

High Priority:Yes

Quality Domain:Person & Caregiver-Centered Experience & Outcome

Description:The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure

Measure Developer/Steward: Minnesota Community Measurement.

MIPS Q473 Average Change in Leg Pain Following Lumbar Fusion Surgery

Type:Outcome

High Priority:Yes

Quality Domain:Person & Caregiver-Centered Experience & Outcome

Description:The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure

Measure Developer/Steward: Minnesota Community Measurement.