Making the Most of Quality Measure Selection

Preparing for reporting to the Merit-based Incentive Payment System (MIPS) can be a daunting task for any clinician, but it could feel especially challenging for a specialist. Much of the MIPS program, including measures in the quality and improvement activities categories, is geared toward primary care practices and clinicians, leaveing few options tailored to specialties such as nephrology and podiatry.

Updates to the CMS QPP Website

The Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP) website offers a tool where measures and activities can be individually added to a ‘shopping cart’ to be downloaded and reviewed at once. CMS has also made the measure filters available which enable you to select only high priority measures or measures that can be reported through registry or claims display. You may further filter the measures by 30 different specialties.

High Priority Measures

As eligible clinicians (ECs) evaluate the available measure sets for the quality category, what if you are a rheumatologist and you don’t see a measure set for your specialty? For ECs that may not fit into these specialty categories, there are other quality measures to which to choose. These measures may involve workflows ECs may already be performing in their daily practice. Of the six quality measures that must be reported on, at least one must be a high priority or outcome measure. Examples of high priority measures are:

  • Controlling High Blood Pressure (Quality ID # 236)
  • Adult Kidney Disease: Blood Pressure Management (Quality ID # 122)
  • Medication Reconciliation Post-Discharge (Quality ID # 046)
  • Care Plan (Quality ID # 047)
  • Documentation of Current Medications in the Medical Record (Quality ID # 130)
  • Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Quality ID #226)

Population Measures

Measures can also be selected based on populations that ECs mainly serve. For ECs that treat the geriatric population, they may choose to report on:

  • Use of High-Risk Medications in the Elderly (Quality ID # 238)
  • Elder Maltreatment Screen and Follow-Up Plan (Quality ID # 181)

Process Measures

ECs that participate in antibiotic stewardship may choose to report on:

  • Appropriate Treatment for Children with Upper Respiratory Infection (URI) (Quality ID # 065)
  • Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (Quality ID # 116)

Other Process Measures

  • Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (Quality ID 317)
  • Evaluation or Interview for Risk of Opioid Misuse (Quality ID # 414)
  • Osteoporosis Management in Women Who Had a Fracture (Quality ID # 418)
  • Diabetes Foot Exam (Quality ID # 163)
Tips for ECs

Here are a few tips if your specialty is not included in the QPP CMS specialty measure set:

  1. Review your workflow for what you are currently doing that could be counted as measures, and ensure adequate data is captured.
  2. If you reported for the Physician Quality Reporting System (PQRS) in previous years, check for comparable measures in the Quality performance category of MIPS. Most measures were carried over from PQRS.
  3. Contact your specialty association (i.e., the American Rheumatology Association) to see what others nationally are doing.
  4. Check in with the New England Quality Payment Program Support Center for assistance in selecting measures that are appropriate for your practice to ensure successful MIPS reporting.
Measure Title Quality ID Outcome or High Priority Submission Method
Care Plan 047 High Priority Claims, Registry
Controlling High Blood Pressure 236 Outcome Claims, CMS Web Interface, EHR, Registry
Adult Kidney Disease: Blood Pressure Management 122 Outcome Registry
Medication Reconciliation Post-Discharge 046 High Priority Claims, CMS Web Interface, Registry
Documentation of Current Medications in the Medical Record 130 High Priority Claims, EHR, Registry
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 Neither Claims, CMS Web Interface, EHR, Registry
Elder Maltreatment Screen and Follow-Up 181 High Priority Claims, Registry
Appropriate Treatment for Children with Upper Respiratory Infection (URI) 065 High Priority EHR, Registry
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 116 High Priority Registry
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 317 Neither Claims, EHR, Registry
Osteoporosis Management in Women Who Had a Fracture 418 Neither Claims, Registry