MIPS eligible clinicians must report six (6) measures during the 12-month MIPS reporting year. If fewer than six (6) measures apply to the eligible clinician, the eligible clinician must report on all applicable measures. One (1) of the six (6) measures must be an outcome measure. If there is no applicable outcome measure, the eligible clinician must report a high priority measure instead. High priority measures are defined as those that measure appropriate use, patient safety, efficiency, patient experience or care coordination. Eligible clinicians are no longer required to report across multiple National Quality Strategy (NQS) domains.
Reporting a cross-cutting measure is NOT required under MIPS.
MIPS eligible clinicians may select their measures from a list of all MIPS measures or from a set of specialty-specific measures. Measure specifications for performance year 2017 are available on the CMS Quality Payment Program website. Remember that measure specifications may have changed from previous years. Practices should make sure they are accurately reporting quality measures for the current performance year.
CMS finalized the Anesthesiology Specialty-Specific Measure Set for physician anesthesiologists for performance year 2017:
- MIPS #44: CABG: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
- MIPS #76: Prevention of 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 Measure: Procedure Room to PACU*
- MIPS #427: Post-Anesthetic Transfer of Care Measure: Procedure Room to ICU*
- MIPS #430: Prevention of PONV - Combination Therapy*
* designates a proposed "high priority measure"
MIPS eligible clinicians reporting via QCDR have the option of reporting both non-MIPS measures and MIPS program measures. CMS does not expect to approve non-MIPS QCDR measures for use until early 2017. ASA and AQI will provide additional information on the available measures for reporting via QCDR in January 2017.
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