Clinical Quality Measures for
MIPS Reporting Period 2023
- 12-Month Reporting Period (January 1st-December 31st)
- Report on 6 Individual Measures
1 must be an outcome measure OR a high-priority measure (if an outcome is not available)
Report a specialty measure set. If the set contains fewer than 6 measures, you must submit all measures within the set.
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)
- 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:
1st Year: Measure will be scored on a scale from 7-10 points
2nd 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:
1st Year: Measure will earn 7 points
2nd Year: Measure will earn 5 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.
- 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.
- 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.
The following lists the eCQMs for 2023. Detailed instructions for fulfilling these measures are forthcoming, check back later for details.
eCQM / NQF ID
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
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|
eCQM / NQF ID
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|