2017 MIPS quality measures

AAD ID  MIPS/NQF ID  Measure name Description Type  CMS derm specialty set  High priority 
01  MIPS 224
NQF 0562
Melanoma: Overutilization of Imaging Studies in Melanoma  Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.  Process  Yes Yes
02 a & b  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.  Process  Yes Yes
03  MIPS 137
NQF 0650 
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. 
Structure  Yes Yes
04  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 by the performing physician.


05 MIPS 337 Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly 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
Process  Yes No
06  MIPS 410  Psoriasis: Clinical Response to Oral Systemic or Biologic Medications  Percentage of psoriasis patients receiving oral systemic or biologic therapy 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.  Outcome  Yes Yes
13  MIPS 440  Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician 
Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date.  Process  No Yes
14  MIPS 46 
NQF 0097 
Medication Reconciliation Post-Discharge   The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. 
This measure is reported as three rates stratified by age group: 
Reporting Criteria 1: 18-64 years of age 
Reporting Criteria 2: 65 years and older 
Total Rate: All patients 18 years of age and older
Process  No Yes
15  MIPS 47 NQF 0326   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.  Process  No Yes
16  MIPS 110 
NQF 0041
CMS147v6
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.  Process  No No
17  MIPS 111
NQF 0043
CMS127v5 
Pneumonia Vaccination Status for Older Adults  Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.   Process  No  No
18  MIPS 128
NQF 0421
CMS69v5
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 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 – 64 years BMI ≥ 18.5 and < 25 kg/m2. 
 
 
Process  No No
19  MIPS 130
NQF 0419
CMS68v6  
Documentation of Current Medications in the Medical Record   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.   Process  Yes Yes
20 MIPS 131
NQF 0420 
Pain Assessment and Follow-Up  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. 
Process  No  Yes
21  MIPS 431
NQF 2152 
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 24 months AND who received brief counseling if identified as an unhealthy alcohol user.   Process  No No
22  MIPS 317
CMS22v5 
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented  
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.   Process  Yes No
23  MIPS 205
NQF 0409 
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.   Process No No
24 MIPS 226
NQF 0028
CMS138v5  
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 24 months AND who received cessation counseling intervention if identified as a tobacco user.  Process  Yes No
25  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.  Process No  Yes
26  MIPS 397  Melanoma Reporting  Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate.  Outcome  No Yes
36  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.   Process  Yes No
37  MIPS 374
CMS 50v5 
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.  Process  Yes Yes