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2021 quality measures for MIPS reporting


Access individual 2021 quality measures for MIPS by clicking the links in the table below. You can also access 2020 measures.

NumberNameDescription

MIPS 137

Melanoma: Continuity of Care – Recall System

Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12-month period, into a recall system that includes: 

  • A target date for the next complete physical skin exam, AND
  • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment.

MIPS 138

Melanoma: Coordination of Care

Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

MIPS 265

Biopsy Follow-Up

Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.

MIPS 337

Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier

Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.

MIPS 410

Psoriasis: Clinical Response to Systemic Medications

Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.

MIPS 440

Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician

Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.

MIPS 47

Advance Care Plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

MIPS 110 

Preventive Care and Screening: Influenza Immunization

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.

MIPS 111

Pneumococcal Vaccination Status for Older Adults

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

MIPS 128

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

Percentage of patients aged 18 years and older with a BMI documented during the current encounter within the previous twelve months AND who had a follow-up plan is documented if most recent BMI was outside normal parameters.

MIPS 130

Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.

MIPS 205

HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection.

MIPS 226

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

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user.

MIPS 317

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is prehypertensive or hypertensive.

MIPS 358

Patient-Centered Surgical Risk Assessment and Communication

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.

MIPS 374

Closing the Referral Loop: Receipt of Specialist Report

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.

MIPS 397

Melanoma Reporting

Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration, and mitotic rate.

MIPS 402

Tobacco Use and Help with Quitting Among Adolescents

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.

MIPS 431

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

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 12 months AND who received brief counseling if identified as an unhealthy alcohol user.

Access individual reporting measures for QCDR by clicking the links in the table below.

Number
Name
Description

AAD 6

Skin Cancer: Biopsy Reporting Time – Clinician to Patient

Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma or melanoma (including in situ disease) or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.

Psoriasis: Screening for Psoriatic Arthritis
Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at each visit.
Chronic Skin Conditions: Patient Reported Quality-of-Life
The percentage of patients aged 18 years and older with a chronic skin condition whose self-assessed quality-of-life was recorded at least once in the medical record within the measurement period.
Psoriasis – Improvement in Patient-Reported Itch Severity
The percentage of patients, aged 18 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.
Dermatitis – Improvement in Patient-Reported Itch Severity
The percentage of patients, aged 18 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient reported itch severity assessments performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.
AAD 11
Skin Cancer Surgery: Post-Operative Complications
Percentage of patients, regardless of age, with a diagnosis of basal cell carcinoma, squamous cell carcinoma, or melanoma (including in situ disease) with a post-operative complication including infection, bleeding, or hematoma following a scalpel-based surgical procedure or Mohs surgery within 15 days of the procedure.
Melanoma: Appropriate Surgical Margins
Percentage of primary excisional surgeries for melanoma or melanoma in situ with Breslow depth and appropriate surgical margins per the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology- Melanoma (NCCN Guideline).

ASPS 27

Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Resection Procedures
Percentage of procedures in patients aged 18 and older with a diagnosis of skin cancer who underwent intermediate layer or complex linear closure or reconstruction after skin cancer resection in the office-based setting who were prescribed post-operative systemic antibiotics to be taken immediately following reconstruction surgery. (Inverse measure.) 

This measure is stratified by intermediate layer or complex linear closure or reconstructive procedures.
Continuation of Anticoagulation Therapy in the Office-based Setting for Closures and Reconstruction After Skin Cancer Resection Procedures
Percentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, on prescribed anticoagulation therapy, who had intermediate layer and/or complex linear closures OR reconstruction after skin cancer resection performed in the office-based setting where anticoagulant therapy was continued prior to surgery.

This measure is stratified by intermediate layer or complex linear closures AND reconstructive procedures.
Avoidance of Opioid Prescriptions for Closures and Reconstruction After Skin Cancer Resection
Percentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, who had intermediate layer and/or complex linear closures OR reconstruction after skin cancer resection where opioid/narcotic therapy was prescribed as first line therapy (as defined by a prescription in anticipation of or at time of surgery) for post-operative pain management by the reconstructing surgeon. (Inverse measure.)

This measure is stratified by intermediate layer or complex linear closures and reconstructive procedures.

This table shows measures that are topped out. Bold measures have a 7-point cap.

Registry reporting
Claims reporting
EHR reporting
MIPS 130
MIPS 47
MIPS 130
MIPS 138
MIPS 128
MIPS 265
MIPS 130
MIPS 397
MIPS 397
MIPS 402

MIPS 440



What is a topped-out measure?

A topped-out measure is one in which historical performance is consistently high and meaningful distinctions and improvement in performance can no longer be measured.

A measure is topped out if the median performance rate is 95% or higher (for non-inverse measures) or is 5% or lower (for inverse measures). This is based on historical data submitted to CMS. In some circumstances, CMS will choose to limit the number of points that can be earned by reporting a topped-out measure to a 7-point cap.

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