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Experience. Integrity. Advocacy.

Choosing Your MIPS Quality Measures

Recently, CIPROMS offered six steps for preparing for the Medicare Quality Payment Program’s (QPP) Merit-based Incentive Payment System (MIPS) for the 2017 reporting year. Many of those steps are simple with a limited number of options, like determining eligibility, picking your pace, and choosing whether to participate as a group or individual.

However, steps number four, choosing your data submission option, and number five, choosing which measures you will perform, may take a little more analysis, especially as you consider which measures are available for which reporting option and make sense for your practice.

For some specialties, like anesthesiology, the Centers for Medicare and Medicaid Services (CMS) has created Specialty Measure Sets which include a variety of measures that may apply to providers in that specialty. Providers in those specialties don’t have to report all or any of those measures among their required six, but these are measures most likely to apply to their procedures and services.

Measures in the anesthesia specialty measure set include:

  • MIPS 044: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
  • MIPS 076: Prevention of Central Venous Catheter (CVC) Related Bloodstream Infections
  • MIPS 130: Documentation of Current Medications in the Medical Record
  • MIPS 317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • MIPS 404: Anesthesiology Smoking Abstinence
  • MIPS 424: Perioperative Temperature Management
  • MIPS 426: Post-Anesthetic Transfer of Care: Procedure Room to Post Anesthetic Care Unit (PACU)
  • MIPS 427: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
  • MIPS 430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

Providers also need to perform at least one outcomes measure, or one high priority measure if an outcomes measure doesn’t apply, in order to receive maximum credit. According to the American Society of Anesthesiologists, that group successfully advocated to CMS to define MIPS 424 as an outcome measure, “thus increasing physician anesthesiologists’ opportunity to report outcome measures in the quality component of MIPS.” As well, seven of the nine measures in the anesthesia specialty set are considered high priority measures (all but MIPS 44 and MIPS 317).

Also, as with PQRS, eligible providers using the Qualified Clinical Data Registry (QCDR) reporting option can perform MIPS and/or non-MIPS measures to fulfill the quality component requirement. The ASA expects to release their non-MIPS QCDR measures in early 2017. The Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) will self-nominate with CMS to continue its designation as a Qualified Registry (QR) and a QCDR for practices participating in the QPP in 2017. In addition to offering submission of more than 20 MIPS measures, plus many non-MIPS measures, for the Quality category, AQI also will provide attestation support for the Improvement Activities category and for patient-facing eligible clinicians in the Advancing Care Information category.

Providers can search for measures in all MIPS categories, including Quality measures by specialty measure set, data submission method, and high priority status, on the Explore Measures tab of CMS’s QPP website. Also, providers can download complete Quality measure specifications from the Education tab of the QPP website. According to CMS, measures currently listed are a “preview” of the final measures which will be posted by December 31, 2016.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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