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2023 quality measures for MIPS reporting


2023 QCDR measure specifications

Access a spreadsheet of 2023 QCDR measure specifications.

Access quality measures specifications for MIPS by clicking the links in the table below. You can also access 2022 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 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 485Psoriasis – Improvement in Patient-Reported Itch SeverityThe 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.
MIPS 486Dermatitis – Improvement in Patient-Reported Itch SeverityThe 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 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.

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 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 176Tuberculosis Screening Prior to First Course Biologic TherapyIf a patient has been newly prescribed a biologic disease-modifying anti-rheumatic drug (DMARD) therapy, then the medical record should indicate TB testing in the preceding 12-month period.

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 the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months 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 elevated 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, thickness, ulceration, mitotic rate, peripheral and deep margin status, and presence or absence of microsatellitosis for invasive tumors.

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.

MIPS 487Screening for Social Drivers of HealthPercent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

Access specifications for QCDR measures 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 10 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.
Skin Cancer Surgery: Post-Operative Complications
Percentage of procedures for basal cell carcinoma, squamous cell carcinoma, or melanoma (including in situ disease) with a post-operative complication including infection, bleeding, or hematoma following an excisional or Mohs surgery within 15 days of the procedure (inverse measure).
AAD 12Melanoma: Appropriate Surgical MarginsPercentage 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)
AAD 14Melanoma: Tracking and Evaluation of RecurrencePercentage of patients who had an excisional surgery for melanoma or melanoma in situ with initial AJCC staging of 0, I, or II, in the past 5 years in which the operating provider examines and/or diagnoses the patient for recurrence of melanoma.
AAD 15Psoriasis – Appropriate Assessment & Treatment of Severe PsoriasisPercentage of patients with a diagnosis of severe psoriasis without a documented Body Surface Area (BSA) or a documented BSA greater than 10% for whom phototherapy or an oral systemic or biologic medication was prescribed.

AAD 16

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.

AAD 17

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.

AAD 18

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.

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