MVP ID: G0055
Most applicable medical specialty(s):
Cardiology, Internal Medicine, Family Medicine
The Advancing Care for Heart Disease MVP focuses on the clinical theme of providing fundamental treatment and management of costly clinical conditions that contribute to, or may result from, heart disease.
Measures/Activites and Requirements (MVP ID: G0055):
To fulfill quality requirements:
- You must select 4 quality measures from the list below
- (exception for clinicians in a small practice - see # 3 below)
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- This MVP includes an outcome measure calculated by CMS through administrative claims. If you select it as 1 of your 4 required quality measures, this must be included in your MVP registration.
- TIP: Before selecting an outcomes-based administrative claims measure, make sure your patient population will allow you to meet the case minimum; if not, you'll receive 0 achievement points for the measure. If you're unsure if you’ll meet the case minimum, you may want to report an additional outcome measure.
- If you are part of a small practice (i.e., 15 or fewer clinicians) reporting quality measures through Medicare Part B claims, you don't need to report additional measures beyond the Medicare Part B claims measures available in this MVP. Reporting all of the Medicare Part B claims measures in this MVP will fulfill your quality reporting requirements.
- You must collect data for each measure for the 12-month performance period of the associated performance year (e.g., January 1, 2024 - December 31, 2024).
TIP: For small practices (participating at the individual, group or subgroup level) reporting Medicare Part B claims measures: To meet data completeness requirements, you'll need to start reporting the Medicare Part B claims measures in your selected MVP in January 2024, prior to the MVP registration period.
TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don't meet case minimum or data completeness criteria will earn zero points.
| Measure | Measure Description | Collection Type | Specification(s) | |
|---|---|---|---|---|
| Measure | Quality ID: 005 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) Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current... | Electronic clinical quality measures (eCQMs) MIPS clinical quality measures (MIPS CQMs) | Review Q005 eCQM SpecificationDownload Q005 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 006 Coronary Artery Disease (CAD): Antiplatelet Therapy Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) see... | MIPS clinical quality measures (MIPS CQMs) | Download Q006 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 007 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen with... | Electronic clinical quality measures (eCQMs) MIPS clinical quality measures (MIPS CQMs) | Review Q007 eCQM SpecificationDownload Q007 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current... | Electronic clinical quality measures (eCQMs) MIPS clinical quality measures (MIPS CQMs) | Review Q008 eCQM SpecificationDownload Q008 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 047 Advance Care Plan Measure Type: Process High Priority: Yes | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision m... | MIPS clinical quality measures (MIPS CQMs) Medicare Part B claims measures | Download Q047 MIPS CQM Specification (PDF)Download Q047 Medicare Part B Claims Specification (PDF) |
| Measure | Quality ID: 118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen with... | MIPS clinical quality measures (MIPS CQMs) | Download Q118 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with a BMI documented during the current encounter or... | Electronic clinical quality measures (eCQMs) MIPS clinical quality measures (MIPS CQMs) Medicare Part B claims measures | Review Q128 eCQM SpecificationDownload Q128 MIPS CQM Specification (PDF)Download Q128 Medicare Part B Claims Specification (PDF) |
| Measure | Quality ID: 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan Measure Type: Process High Priority: No | Percentage of patients aged 12 years and older screened for depression on the date of the encounter ... | Electronic clinical quality measures (eCQMs) MIPS clinical quality measures (MIPS CQMs) Medicare Part B claims measures | Review Q134 eCQM SpecificationDownload Q134 MIPS CQM Specification (PDF)Download Q134 Medicare Part B Claims Specification (PDF) |
| Measure | Quality ID: 238 Use of High-Risk Medications in Older Adults Measure Type: Process High Priority: Yes | Percentage of patients 65 years of age and older who were ordered at least two high-risk medications... | Electronic clinical quality measures (eCQMs) MIPS clinical quality measures (MIPS CQMs) | Review Q238 eCQM SpecificationDownload Q238 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting Measure Type: Process High Priority: Yes | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have exp... | MIPS clinical quality measures (MIPS CQMs) | Download Q243 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Measure Type: Process High Priority: No | Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who w... | MIPS clinical quality measures (MIPS CQMs) | Download Q326 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 377 Functional Status Assessments for Heart Failure Measure Type: Process High Priority: Yes | Percentage of patients 18 years of age and older with heart failure who completed initial and follow... | Electronic clinical quality measures (eCQMs) | Review Q377 eCQM Specification |
| Measure | Quality ID: 392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation Measure Type: Outcome High Priority: Yes | Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This mea... | MIPS clinical quality measures (MIPS CQMs) | Download Q392 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 393 Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Measure Type: Outcome High Priority: Yes | Infection rate following CIED device implantation, replacement, or revision.... | MIPS clinical quality measures (MIPS CQMs) | Download Q393 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) Measure Type: Intermediate Outcome High Priority: Yes | The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goal... | MIPS clinical quality measures (MIPS CQMs) | Download Q441 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 487 Screening for Social Drivers of Health Measure Type: Process High Priority: Yes | Percent of patients 18 years and older screened for food insecurity, housing instability, transporta... | MIPS clinical quality measures (MIPS CQMs) | Download Q487 MIPS CQM Specification (PDF) |
| Measure | Quality ID: 503 Gains in Patient Activation Measure (PAM) Scores at 12 Months Measure Type: Patient Reported Outcome High Priority: Yes | The Patient Activation Measure (PAM) (Registered Trademark) is a 10- or 13- item questionnaire that ... | MIPS clinical quality measures (MIPS CQMs) | Download Q503 MIPS CQM Specification (ZIP) |
| Measure | Quality ID: 492 Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System Measure Type: Outcome High Priority: Yes | Annual risk-standardized rate of acute, unplanned cardiovascular-related admissions among Medicare F... | Administrative claims measures | Download 2024 Q492 Measure Specifications (ZIP) |
You must report 1 of the following 3 options:
1. Two medium weighted improvement activities from the list below, or
2. One high weighted improvement activity from the list below, or
3. The IA_PCMH activity (participation in a certified or recognized patient-centered medical home or a comparable specialty practice).
Download 2024 Improvement Activities Inventory (ZIP)| Activity | Activity Description | Activity Weighting | |
|---|---|---|---|
| Activity | Activity ID: IA_AHE_12 Practice Improvements that Engage Community Resources to Address Drivers of Health | Select and screen for drivers of health that are relevant for the eligible clinician’s population us... | high |
| Activity | Activity ID: IA_AHE_9 Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols | Create or improve, and then implement, protocols for identifying and providing appropriate support t... | medium |
| Activity | Activity ID: IA_BE_12 Use evidence-based decision aids to support shared decision-making. | Use evidence-based decision aids to support shared decision-making.... | medium |
| Activity | Activity ID: IA_BE_15 Engagement of Patients, Family, and Caregivers in Developing a Plan of Care | Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals fo... | medium |
| Activity | Activity ID: IA_BE_24 Financial Navigation Program | In order to receive credit for this activity, MIPS eligible clinicians must attest that their practi... | medium |
| Activity | Activity ID: IA_BE_25 Drug Cost Transparency | Provide counseling to patients and/or their caregivers regarding: costs of medications using a real ... | high |
| Activity | Activity ID: IA_BE_6 Regularly Assess Patient Experience of Care and Follow Up on Findings | Collect and follow up on patient experience and satisfaction data. This activity also requires follo... | high |
| Activity | Activity ID: IA_CC_9 Implementation of practices/processes for developing regular individual care plans | Implementation of practices/processes, including a discussion on care, to develop regularly updated ... | medium |
| Activity | Activity ID: IA_MVP Practice-Wide Quality Improvement in MIPS Value Pathways | Create a quality improvement initiative within your practice and create a culture in which all staff... | high |
| Activity | Activity ID: IA_PCMH Electronic submission of Patient Centered Medical Home accreditation | I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has ... | |
| Activity | Activity ID: IA_PM_13 Chronic Care and Preventative Care Management for Empaneled Patients | In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and prev... | medium |
| Activity | Activity ID: IA_PM_14 Implementation of methodologies for improvements in longitudinal care management for high risk patients | Provide longitudinal care management to patients at high risk for adverse health outcome or harm tha... | medium |
| Activity | Activity ID: IA_PSPA_4 Administration of the AHRQ Survey of Patient Safety Culture | Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparativ... | medium |
| Activity | Activity ID: IA_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements | Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice... | medium |
Important information to consider:
- You don’t have to submit any data for this performance category. We'll use Medicare claims data to calculate your cost measure performance.
- You don't select cost measures during MVP registration. CMS will calculate your performance on all the cost measures included in the MVP based on available Medicare claims data.
- You'll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.
| Measure | Description | Specification(s) | |
|---|---|---|---|
| Measure | Measure ID: COST_EOPCI_1 Elective Outpatient Percutaneous Coronary Intervention (PCI) | Episode-based cost measures represent the cost to Medicare for the items and services provided to a ... | |
| Measure | Measure ID: COST_HF_1 Heart Failure | Patients receiving medical care to manage and treat heart failure. This chronic condition measure in... | |
| Measure | Measure ID: COST_STEMI_1 ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) | Episode-based cost measures represent the cost to Medicare for the items and services provided to a ... | |
| Measure | Measure ID: MSPB_1 Medicare Spending Per Beneficiary (MSPB) Clinician | The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a r... | |
| Measure | Measure ID: TPCC_1 Total Per Capita Cost (TPCC) | The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primar... |
To fulfill Promoting Interoperability requirements:
- Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren't required.
- If you're reporting as a subgroup, you'll submit your affiliated group's data for the Promoting Interoperability performance category.
- Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.
Clinician Types for Automatic Reweighting:
- Clinical social worker
Special Status for Automatic Reweighting:
- Ambulatory Surgical Center (ASC)-based
- Hospital-based
- Non-patient facing
- Small practice
Promoting Interoperability Performance Category Hardship Exception Qualifications:
- Decertified EHR technology
- Insufficient internet connectivity
- Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
- Lack control over availability of CEHRT (Certified Electronic Health Record Technology)
Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.
| Measure | Objective name | Required/Optional | Specification(s) | |
|---|---|---|---|---|
| Measure | Measure ID: PI_EP_1 e-Prescribing | Electronic Prescribing | Required | |
| Measure | Measure ID: PI_EP_2 Query of the Prescription Drug Monitoring Program (PDMP) | Electronic Prescribing | Required | |
| Measure | Measure ID: PI_EP_2_EX_1 Query of the Prescription Drug Monitoring Program (PDMP) Exclusion | Electronic Prescribing | Optional | |
| Measure | Measure ID: PI_EP_2_EX_2 Query of the Prescription Drug Monitoring Program (PDMP) Exclusion | Electronic Prescribing | Optional | |
| Measure | Measure ID: PI_HIE_1 Support Electronic Referral Loops By Sending Health Information | Health Information Exchange | Required, unless submitting PI_HIE_5 or PI_HIE_6 | |
| Measure | Measure ID: PI_HIE_4 Support Electronic Referral Loops By Receiving and Reconciling Health Information | Health Information Exchange | Required, unless submitting PI_HIE_5 or PI_HIE_6 | |
| Measure | Measure ID: PI_HIE_5 Health Information Exchange (HIE) Bi-Directional Exchange | Health Information Exchange | Required, unless submitting PI_HIE_6 or the combination of PI_HIE_1 and PI_HIE_4 | |
| Measure | Measure ID: PI_HIE_6 Enabling Exchange Under TEFCA | Health Information Exchange | Required, unless submitting PI_HIE_5 or the combination of PI_HIE_1 and PI_HIE_4 | |
| Measure | Measure ID: PI_INFBLO_1 Actions to Limit or Restrict the Compatibility of CEHRT | Attestation | Required | |
| Measure | Measure ID: PI_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion | Health Information Exchange | Optional | |
| Measure | Measure ID: PI_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion | Health Information Exchange | Optional | |
| Measure | Measure ID: PI_LVPP_1 e-Prescribing Exclusion | Electronic Prescribing | Optional | |
| Measure | Measure ID: PI_ONCACB_1 ONC-ACB Surveillance Attestation | Attestation | Optional | |
| Measure | Measure ID: PI_ONCDIR_1 ONC Direct Review Attestation | Attestation | Required | |
| Measure | Measure ID: PI_PEA_1 Provide Patients Electronic Access to Their Health Information | Provider To Patient Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_1 Immunization Registry Reporting | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_1_EX_1 Immunization Registry Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_1_EX_2 Immunization Registry Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_1_EX_3 Immunization Registry Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_1_PRE Immunization Registry Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_1_PROD Immunization Registry Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_2 Syndromic Surveillance Reporting | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_2_PRE Syndromic Surveillance Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_2_PROD Syndromic Surveillance Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_3 Electronic Case Reporting | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_3_EX_1 Electronic Case Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_3_EX_2 Electronic Case Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_3_EX_3 Electronic Case Reporting Exclusion | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_3_PRE Electronic Case Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_3_PROD Electronic Case Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_4 Public Health Registry Reporting | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_4_PRE Public Health Registry Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_4_PROD Public Health Registry Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_5 Clinical Data Registry Reporting | Public Health And Clinical Data Exchange | Optional | |
| Measure | Measure ID: PI_PHCDRR_5_PRE Clinical Data Registry Reporting Active Engagement Level 1 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PHCDRR_5_PROD Clinical Data Registry Reporting Active Engagement Level 2 | Public Health And Clinical Data Exchange | Required | |
| Measure | Measure ID: PI_PPHI_1 Security Risk Analysis | Protect Patient Health Information | Required | |
| Measure | Measure ID: PI_PPHI_2 SAFER Guides High Priority Practices Guide | Protect Patient Health Information | Required |
You must select 1 population health measure at the time of MVP registration.
- You don't have to submit any data for this measure, we'll calculate the population health measures for you using administrative claims data.
- This measure will be excluded from scoring if the measure doesn't have a benchmark or meet the case minimum.
- Population health isn't a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.
- Subgroups will be evaluated at the affiliated group level.
| Quality | Description | Collection Type | Specification(s) | |
|---|---|---|---|---|
| Quality | Quality ID: 479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups Measure Type: Outcome High Priority: Yes | This measure is a re-specified version of the measure, "Risk-adjusted readmission rate (RARR) of unp... | Administrative claims measures | |
| Quality | Quality ID: 484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions Measure Type: Outcome High Priority: Yes | Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service... | Administrative claims measures |
Looking for a different MVP? Head back to Explore MIPS Value Pathways (MVPs)