Clinical Quality Measures for
MIPS Reporting Period 2024

Requirements:

  • 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)
    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)
  • Medicare CQMs – Can ONLY be reported under the APP. This is NOT available for Traditional MIPS

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 (75%) 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

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 59 existing quality measures
  • Removal of 11 quality measures, and partially removed 3 quality measures from traditional MIPS but retained for MVPs
  • 11 New quality measures, including 1 composite measure and 6 high priority measures, of which 4 are patient-reported outcome measures.

 

Outcome Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Diabetes: Hemoglobin A1c Poor Control (>9%) CMS122v12 / None Yes No
Depression Remission at Twelve Months CMS159v12 / None Yes No
Controlling High Blood Pressure CMS165v12 / None Yes No

High Priority Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Closing the Referral Loop: Receipt of Specialist Report CMS50v12 / None Yes No
Documentation of Current Medications in the Medical Record CMS68v13 / None Yes Yes
Functional Status Assessment for Congestive Heart Failure CMS90v13 / None Yes No
Screening for Future Falls Risk CMS139v12 / None Yes No
Appropriate Testing for Pharyngitis CMS146v12 / None Yes No
Appropriate Treatment for Upper Respiratory Infection (URI) CMS154v12 / None Yes No
Use of High-Risk Medications in the Elderly CMS156v12 / None Yes Yes

Other Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Preventive Care and Screening: Screening for Depression and Follow-Up Plan CMS2v13 / None Yes No
Cervical Cancer Screening CMS124v12 / None Yes No
Diabetes: Eye Exam CMS131v12 / 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) CMS135v12 / 0081e Yes No
Follow-Up Care for Children Prescribed ADHD Medication (ADD) CMS136v13 / None Yes No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS138v12 / 0028e Yes No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS144v12 / 0083e Yes No
Dementia: Cognitive Assessment CMS149v12 / 2872e Yes No
Chlamydia Screening for Women CMS153v12 / None Yes No
Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents CMS155v12 / None Yes No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS347v7 / None Yes No
Kidney Health Evaluation CMS951v2 / None Yes No

Not Available for Traditional MIPS

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan CMS69v12 / None No No
Breast Cancer Screening CMS125v12 / None Yes No
Pneumococcal Vaccination Status for Older Adults CMS127v11 / None Yes No
Colorectal Cancer Screening CMS130v12 / None Yes No
Preventive Care and Screening: Influenza Immunization CMS147v12 / 0041e Yes No