Clinical Quality Measures for
MIPS Reporting Period 2023

Requirements:

• 12-Month Reporting Period (January 1^st-December 31^st)
• Report on 6 Individual Measures
  1 must be an outcome measure OR a high-priority measure (if an outcome is not available)
  OR
  Report a specialty measure set. If the set contains fewer than 6 measures, you must submit all measures within the set.

Collection Type:

Refers to the way you collect quality measure data.
You can submit measures from different collection types:

• eCQMs (Electronic Clinical Quality Measures)
• Medicare Part B Claims (Small Practice Only)
• MIPS CQMs (MIPS Clinical Quality Measures)
• QCDR (Qualified Clinical Data Registry Measures)

Scoring

• 30% of Final Score

Scoring Policies for Quality Measures:

Existing Measures – That can be reliably scored against a benchmark (historical or performance period), meet data completeness (70%) and case volume (20) will be scored on a scale from 1-10 or 1-7 for Topped-out measures.

• • • Measures without a benchmark (historical or performance period) will earn 0 points, except for small practice will continue to earn 3 points.
    • Measures that do not meet case volume or data completeness will earn 0 points, except for a small practice will continue to earn 3 points.

New Measures – When a performance period benchmark can be created, and data completeness (70%) and case volume (20) is met:

1^st Year: Measure will be scored on a scale from 7-10 points

2^nd Year: Measure will be scored on a scale from 5-10 points

If a performance period benchmark cannot be established and/or case volume was not met:

1^st Year: Measure will earn 7 points

2^nd Year: Measure will earn 5 points

Bonus Points:

• Small Practice Bonus (15 EC or less)

6 bonus points will be added to the quality category for clinicians in small practices who submit at least 1 measure, either individually or as a group or virtual group. This bonus is not added to clinicians or groups who are scored under facility-based scoring.

Improvement Scoring:

• Will be based on the rate of improvement such that higher improvement results in more points for those who have not previously performed well.
• Improvement will be measured at the performance category level.
• Up to 10 percentage points available.

Measure Inventory:

• Substantive changes to 76 existing quality measures, 5 of which won’t have a historical benchmark
• Removal of 11 quality measures, and partially removed 2 quality measures from traditional MIPS but retained for MVPs
• 9 New quality measures, including 1 administrative claim measure.

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The following lists the eCQMs for 2023. Detailed instructions for fulfilling these measures are forthcoming, check back later for details.

Outcome Measures	eCQM / NQF ID	Telehealth Eligible	7 Point Cap
Diabetes: Hemoglobin A1c Poor Control (>9%)	CMS122v11 / None	Yes	No
Depression Remission at Twelve Months	CMS159v11 / None	Yes	No
Controlling High Blood Pressure	CMS165v11 / None	Yes	No

High Priority Measures	eCQM / NQF ID	Telehealth Eligible	7 Point Cap
Closing the Referral Loop: Receipt of Specialist Report	CMS50v11 / None	Yes	No
Documentation of Current Medications in the Medical Record	CMS68v12 / None	Yes	Yes
Functional Status Assessment for Congestive Heart Failure	CMS90v12 / None	Yes	No
Screening for Future Falls Risk	CMS139v11 / None	Yes	No
Appropriate Testing for Pharyngitis	CMS146v11 / None	Yes	No
Appropriate Treatment for Upper Respiratory Infection (URI)	CMS154v11 / None	Yes	No
Use of High-Risk Medications in the Elderly	CMS156v11 / None	Yes	Yes

Other Measures	eCQM / NQF ID	Telehealth Eligible	7 Point Cap
Preventive Care and Screening: Screening for Depression and Follow-Up Plan	CMS2v12 / None	Yes	No
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	CMS69v11 / None	No	No
Cervical Cancer Screening	CMS124v11 / None	Yes	No
Breast Cancer Screening	CMS125v11 / None	Yes	No
Pneumococcal Vaccination Status for Older Adults	CMS127v11 / None	Yes	No
Colorectal Cancer Screening	CMS130v11 / None	Yes	No
Diabetes: Eye Exam	CMS131v11 / None	Yes	No
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CMS135v11 / 0081e	Yes	No
ADHD: Follow-Up Care for Children Prescribed ADHD Medication	CMS136v12 / None	Yes	No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS138v11 / 0028e	Yes	No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CMS144v11 / 0083e	Yes	No
Preventive Care and Screening: Influenza Immunization	CMS147v12 / 0041e	Yes	No
Dementia: Cognitive Assessment	CMS149v11 / 2872e	Yes	No
Chlamydia Screening for Women	CMS153v11 / None	Yes	No
Weight Assessment & Counseling for Nutrition & Physical Activity for Children and Adolescents	CMS155v11 / None	Yes	No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS347v6 / None	Yes	No
Kidney Health Evaluation	CMS951v1 / None	Yes	No