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Choosing MIPS Quality Measures for Emergency Physicians

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 emergency medicine, 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. Also, some specialties are better suited for some reporting options, depending on the available measures and the specific practice patterns of the group.

The 15 measures below are included in the emergency medicine measure set:

Measure ID Measure Title Reporting Options
47 Care Plan Claims, Registry
66 Appropriate Testing for Children with Pharyngitis EHR, Registry
91 Acute Otitis Externa (AOE): Topical Therapy Claims, Registry
93 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use Claims, Registry
116 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Registry
130 Documentation of Current Medications in the Medical Record Claims, EHR, Registry
226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Claims, CMS Web Interface, EHR, Registry
254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Claims, Registry
255 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure Claims, Registry
317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Claims, EHR, Registry
374 Closing the Referral Loop: Receipt of Specialist Report EHR
402 Tobacco Use and Help with Quitting Among Adolescents Registry
415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Claims, Registry
416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Claims, Registry
431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Registry

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. While none of the 15 measures earmarked for emergency medicine is an outcomes measure, there are seven high priority measures in the list (MIPS 76, MIPS 130, MIPS 404, MIPS 424, MIPS 426, MIPS 427, and MIPS 430).

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 American College of Emergency Physicians will continue their Clinical Emergency Data Registry as a QCDR for practices participating in MIPS in 2017. In addition to offering submission of many MIPS measures, CEDR will also include many non-MIPS measures for the Quality category. According to an article on the ACEP website by Nicholas Genes, MD, PhD, Icahn School of Medicine at Mount Sinai, CEDR can accept regular data uploads or can “pull” data directly from many common ED EHRs, and currently they have 41 measures available.

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.

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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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