Clinical Quality Measures for
MIPS Reporting Period 2020

Overview

You can elect to choose any of the following eCQMs to satisfy the MIPS Quality Performance Category. You must report on 6 measures. One of the 6 measures must be an Outcome Measure.

If an Outcome measure is not applicable to your specialty, you will have to select another High Priority measure. The eCQMs will be reported through EHR reporting which can earn you 1 bonus point for each measure submitted.

Reporting Period

The reporting period is for a full calendar year.

Scoring

  • Each measure will be scored on a scale from 0-10 or 0-7 for Topped Out measures capped at 7 points.
  • Each measure must meet data completeness (70%), case volume (20), and has a measure Benchmark to obtain maximum number of points. Each of the eCQMs listed below has a Benchmark.
  • Measures that fail to meet data completeness: Small Practice (15 or fewer clinicians) will ONLY earn 3 points. Large Practice (16+ clinicians) will receive 0 points.
  • Measures that do not have a benchmark and/or do not meet case volume BUT have meet data completeness: Practice of any size will earn 3 points.
  • Bonus Points will be awarded for reporting on additional Outcome or High Priority measures beyond the required 1 and submitting thru EHR reporting.
  • The eCQMs will factor in all patients, regardless of payer, who meet the denominator description, but you MUST have at least one Medicare beneficiary within the reported population.
  • The Quality performance category will make up 45% of the ECs MIPS Final score. This percentage can change due to Special Statuses, Exception Applications, reweighting of other performance categories, or Alternative Payment Model (APM) participation.

Outcome Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Children Who Have Dental Decay or Cavities CMS75v8 / None Yes Yes
Diabetes: Hemoglobin A1c Poor Control CMS122v8 / None Yes No
Controlling High Blood Pressure CMS165v8 / None Yes No

High Priority Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Closing the Referral Loop: Receipt of Specialist Report CMS50v8 / None Yes No
Documentation of Current Medications in the Medical Record CMS68v8 / 0419e Yes Yes
Functional Status Assessment for Congestive Heart Failure CMS90v9 / None Yes No
Screening for Future Falls Risk CMS139v8 / None Yes No
Appropriate Testing for Children with Pharyngitis CMS146v8 / None Yes No
Appropriate Treatment for Children with Upper Respiratory Infection (URI) CMS154v8 / None Yes No
Use of High-Risk Medications in the Elderly CMS156v8 / None Yes Yes

Other Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan CMS69v8 / 0421e No No
Cervical Cancer Screening CMS124v8 / None Yes No
Breast Cancer Screening CMS125v8 / None Yes No
Pneumococcal Vaccination Status for Older Adults CMS127v8 / None Yes No
Colorectal Cancer Screening CMS130v8 / None Yes No
Diabetes: Eye Exam CMS131v8 / None Yes No
Diabetes: Medical Attention for Nephropathy CMS134v8 / None Yes No
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB)
Therapy for Left Ventricular Systolic Dysfunction (LVSD)		 CMS135v8 / 0081e Yes No
Follow-Up Care for Children Prescribed ADHD Medication (ADD) CMS136v9 / None Yes No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS138v8 / 0028e Yes No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS144v8 / 0083e Yes No
Preventive Care and Screening: Influenza CMS147v9 / 0041e Yes No
Dementia: Cognitive Assessment CMS149v8 / 2872e Yes No
Chlamydia Screening for Women CMS153v8 / None Yes No
Weight Assessment & Counseling for Nutrition & Physical Activity for Children and Adolescents CMS155v8 / None Yes No