MIPS
OBERD is a Qualified Registry and can be used for MIPS reporting directly to CMS. OBERD has a defined 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.
5 reasons why you should choose OBERD for MIPS reporting
- Fully independent reporting system, outside of the EMR, to make it simple on your staff
- CMS audit management on your behalf
- Real-time dashboard to monitor and optimize performance
- Proactive notification on underperforming providers, to help focus your quality- improvement efforts
- Use one form to meet specific quality measures and assist in improvement activities through education
MIPS Quality Measure Education
OBERD meets CMS requirements of quality measures and improvement activities by providing automated patient education on the subjects they need. Our intelligent forms deliver what they need, when they need it, based on the patients' input.
Qualified Registry Supported Measures
OBERD allows you to collect and report independently of your EMR, to meet 45% of the MIPS Composite Performance Score. After initial setup, data collection and reporting requires minimal staff involvement! We do it all for you, including managing CMS audits.
MIPS Measures
All measures below were approved by CMS and qualify for 2023 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 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 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 Q047: Advance Care Plan
Type: Process
High Priority: Yes
Quality Domain: Communication and Care Coordination
Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker document 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.
Measure Developer/Steward: National Committee for Quality Assurance
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 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 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
Quality Domain: CCC
High Priority: Yes
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
Quality Domain: CCC
High Priority: Yes
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
Quality Domain: CCC
High Priority: Yes
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
Quality Domain: CCC
High Priority: Yes
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
Quality Domain: CCC
High Priority: Yes
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
Quality Domain: CCC
High Priority: Yes
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
Quality Domain: CPH
High Priority: No
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 Q318 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
Quality Domain: Person & Caregiver-Centered Experience & Outcome
High Priority: Yes
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
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 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 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 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 Q470 Average Change in Functional Status Following Total Knee Replacement
Type: Outcome
Quality Domain: Person & Caregiver-Centered Experience & Outcome
High Priority: Yes
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 Functional Status Following Lumbar Discectomy/Laminotomy Surgery
Type: Outcome
Quality Domain: Person & Caregiver-Centered Experience & Outcome
High Priority: Yes
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 Q478 Functional Status Change for Patients with Neck Impairments
Type: Outcome
Quality Domain: Person & Caregiver-Centered Experience & Outcome
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with neck impairments. The change in functional status (FD) is assessed using the FOTO Neck FS patient -reported outcome measure (PROM). 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 clinical level, and at the clinical level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paper-pencil).
Measure Developer/Steward: FOTO Measures
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