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Explore MIPS Value Pathways (MVPs) page

MVP ID: M1366

Most applicable medical specialty(s):
Gynecology, Obstetrics, Urogynecology, Nonphysician Practitioners, Certified Nurse Mid-Wives, Nurse Practitioners, Physician Assistants

Focusing on Women’s Health MVP focuses on the clinical theme of providing treatment and management of women’s health.

Measures/Activites and Requirements (MVP ID: M1366):

To fulfill quality requirements:

  1. You must select 4 quality measures from the list below
  2. At least 1 measure must be an outcome measure
    • If no outcome measures are available, you may report a high priority measure.
  3. 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: 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.

Quality Measures (MVP ID: M1366)
MeasureMeasure DescriptionCollection TypeSpecification(s)
Measure

Quality ID: 048

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Measure Type: Process

High Priority: No

Percentage of female patients aged 65 years and older who were assessed for the presence or absence ...

MIPS clinical quality measures (MIPS CQMs)

Download Q048 MIPS CQM Specification (PDF)
Measure

Quality ID: 112

Breast Cancer Screening

Measure Type: Process

High Priority: No

Percentage of women 40 - 74 years of age who had a mammogram to screen for breast cancer in the 27 m...

Electronic clinical quality measures (eCQMs)

MIPS clinical quality measures (MIPS CQMs)

Medicare Part B claims measures

Review Q112 eCQM SpecificationDownload Q112 MIPS CQM Specification (PDF)Download Q112 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: 226

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Measure Type: Process

High Priority: No

Percentage of patients aged 12 years and older who were screened for tobacco use one or more times d...

Electronic clinical quality measures (eCQMs)

MIPS clinical quality measures (MIPS CQMs)

Medicare Part B claims measures

Review Q226 eCQM SpecificationDownload Q226 MIPS CQM Specification (PDF)Download Q226 Medicare Part B Claims Specification (PDF)
Measure

Quality ID: 309

Cervical Cancer Screening

Measure Type: Process

High Priority: No

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the fol...

Electronic clinical quality measures (eCQMs)

Review Q309 eCQM Specification
Measure

Quality ID: 310

Chlamydia Screening for Women

Measure Type: Process

High Priority: No

Percentage of women 16-24 years of age who were identified as sexually active and who had at least o...

Electronic clinical quality measures (eCQMs)

Review Q310 eCQM Specification
Measure

Quality ID: 335

Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)

Measure Type: Outcome

High Priority: Yes

Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live...

MIPS clinical quality measures (MIPS CQMs)

Download Q335 MIPS CQM Specification (PDF)
Measure

Quality ID: 336

Maternity Care: Postpartum Follow-up and Care Coordination

Measure Type: Process

High Priority: Yes

Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for...

MIPS clinical quality measures (MIPS CQMs)

Download Q336 MIPS CQM Specification (PDF)
Measure

Quality ID: 400

One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation

Measure Type: Process

High Priority: No

Percentage of patients age >= 18 years have never been tested for Hepatitis C Virus (HCV) infection ...

MIPS clinical quality measures (MIPS CQMs)

Download Q400 MIPS CQM Specification (PDF)
Measure

Quality ID: 422

Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

Measure Type: Process

High Priority: Yes

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time...

MIPS clinical quality measures (MIPS CQMs)

Medicare Part B claims measures

Download Q422 MIPS CQM Specification (PDF)Download Q422 Medicare Part B Claims Specification (PDF)
Measure

Quality ID: 431

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

Measure Type: Process

High Priority: No

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a s...

MIPS clinical quality measures (MIPS CQMs)

Download Q431 MIPS CQM Specification (PDF)
Measure

Quality ID: 432

Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

Measure Type: Outcome

High Priority: Yes

Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder...

MIPS clinical quality measures (MIPS CQMs)

Download Q432 MIPS CQM Specification (PDF)
Measure

Quality ID: 448

Appropriate Workup Prior to Endometrial Ablation

Measure Type: Process

High Priority: Yes

Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy wi...

MIPS clinical quality measures (MIPS CQMs)

Download Q448 MIPS CQM Specification (PDF)
Measure

Quality ID: 472

Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

Measure Type: Process

High Priority: Yes

Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fra...

Electronic clinical quality measures (eCQMs)

Review Q472 eCQM Specification
Measure

Quality ID: 475

HIV Screening

Measure Type: Process

High Priority: No

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 year...

Electronic clinical quality measures (eCQMs)

Review Q475 eCQM Specification
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: 493

Adult Immunization Status

Measure Type: Process

High Priority: No

Percentage of patients 19 years of age and older who are up-to-date on recommended routine vaccines ...

MIPS clinical quality measures (MIPS CQMs)

Download Q493 MIPS CQM Specification (PDF)
Measure

Quality ID: 496

Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument

Measure Type: Process

High Priority: No

Percentage of pregnant or postpartum patients who received a cardiovascular disease (CVD) risk asses...

MIPS clinical quality measures (MIPS CQMs)

Download Q496 MIPS CQM Specification (PDF)
Measure

Quality ID: UREQA8

Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved

Measure Type: Outcome

High Priority: Yes

Percentage of patients aged 65 years and older diagnosed with osteopenia or osteoporosis whose most ...

Qualified Clinical Data Registry (QCDR)

Download All 2024 QCDR Specifications

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)
Improvement Activities (MVP ID: M1366)
ActivityActivity DescriptionActivity Weighting
Activity

Activity ID: IA_AHE_1

Enhance Engagement of Medicaid and Other Underserved Populations

To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat dat...high
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_3

Promote Use of Patient-Reported Outcome Tools

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresp...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_16

Promote Self-management in Usual Care

To help patients self-manage their care, incorporate culturally and linguistically tailored evidence...medium
Activity

Activity ID: IA_BE_4

Engagement of patients through implementation of improvements in patient portal

To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced pat...medium
Activity

Activity ID: IA_BMH_11

Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice

Create and implement a plan for trauma-informed care (TIC) that recognizes the potential impact of t...medium
Activity

Activity ID: IA_BMH_14

Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women

Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant...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_EPA_2

Use of telehealth services that expand practice access

Create and implement a standardized process for providing telehealth services to expand access to ca...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_23

Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines

Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool...high
Activity

Activity ID: IA_PM_6

Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities (Use of toolset or other resources to close healthcare disparities across communities)

Address inequities in health outcomes by using population health data analysis tools to identify hea...medium

Important information to consider:

  1. 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.
  2. You'll only be scored on the cost measures in this MVP for which you meet or exceed the established case minimum.
Cost Measures (MVP ID: M1366)
MeasureDescriptionSpecification(s)
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...

Download MSPB_1 Specification (PDF)

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...

Download TPCC_1 Specification (PDF)

To fulfill Promoting Interoperability requirements:

  1. 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.
  2. 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.

Promoting Interoperability Measures (All MVPs)
MeasureObjective nameRequired/OptionalSpecification(s)
Measure

Measure ID: PI_EP_1

e-Prescribing

Electronic PrescribingRequired

Review 2024 PI_EP_1 Measure Specification

Measure

Measure ID: PI_EP_2

Query of the Prescription Drug Monitoring Program (PDMP)

Electronic PrescribingRequired

Review 2024 PI_EP_2 Measure Specification

Measure

Measure ID: PI_EP_2_EX_1

Query of the Prescription Drug Monitoring Program (PDMP) Exclusion

Electronic PrescribingOptional

Review 2024 PI_EP_2_EX_1 Measure Specification

Measure

Measure ID: PI_EP_2_EX_2

Query of the Prescription Drug Monitoring Program (PDMP) Exclusion

Electronic PrescribingOptional

Review 2024 PI_EP_2_EX_2 Measure Specification

Measure

Measure ID: PI_HIE_1

Support Electronic Referral Loops By Sending Health Information

Health Information ExchangeRequired, unless submitting PI_HIE_5 or PI_HIE_6

Review 2024 PI_HIE_1 Measure Specification

Measure

Measure ID: PI_HIE_4

Support Electronic Referral Loops By Receiving and Reconciling Health Information

Health Information ExchangeRequired, unless submitting PI_HIE_5 or PI_HIE_6

Review 2024 PI_HIE_4 Measure Specification

Measure

Measure ID: PI_HIE_5

Health Information Exchange (HIE) Bi-Directional Exchange

Health Information ExchangeRequired, unless submitting PI_HIE_6 or the combination of PI_HIE_1 and PI_HIE_4

Review 2024 PI_HIE_5 Measure Specification

Measure

Measure ID: PI_HIE_6

Enabling Exchange Under TEFCA

Health Information ExchangeRequired, unless submitting PI_HIE_5 or the combination of PI_HIE_1 and PI_HIE_4

Review 2024 PI_HIE_6 Measure Specification

Measure

Measure ID: PI_INFBLO_1

Actions to Limit or Restrict the Compatibility of CEHRT

AttestationRequired

Review 2024 PI_INFBLO_1 Fact Sheet

Measure

Measure ID: PI_LVITC_2

Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion

Health Information ExchangeOptional

Review 2024 PI_LVITC_2 Measure Specification

Measure

Measure ID: PI_LVOTC_1

Support Electronic Referral Loops By Sending Health Information Exclusion

Health Information ExchangeOptional

Review 2024 PI_LVOTC_1 Measure Specification

Measure

Measure ID: PI_LVPP_1

e-Prescribing Exclusion

Electronic PrescribingOptional

Review 2024 PI_LVPP_1 Measure Specification

Measure

Measure ID: PI_ONCACB_1

ONC-ACB Surveillance Attestation

AttestationOptional

Review 2024 PI_ONCACB_1 Measure Specification

Measure

Measure ID: PI_ONCDIR_1

ONC Direct Review Attestation

AttestationRequired

Review 2024 PI_ONCDIR_1 Details

Measure

Measure ID: PI_PEA_1

Provide Patients Electronic Access to Their Health Information

Provider To Patient ExchangeRequired

Review 2024 PI_PEA_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_1

Immunization Registry Reporting

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_EX_1

Immunization Registry Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_1_EX_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_EX_2

Immunization Registry Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_1_EX_2 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_EX_3

Immunization Registry Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_1_EX_3 Measure Specification

Measure

Measure ID: PI_PHCDRR_1_PRE

Immunization Registry Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_1_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_1_PROD

Immunization Registry Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_1_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_2

Syndromic Surveillance Reporting

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_2 Measure Specification

Measure

Measure ID: PI_PHCDRR_2_PRE

Syndromic Surveillance Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_2_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_2_PROD

Syndromic Surveillance Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_2_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_3

Electronic Case Reporting

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_3 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_EX_1

Electronic Case Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_3_EX_1 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_EX_2

Electronic Case Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_3_EX_2 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_EX_3

Electronic Case Reporting Exclusion

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_3_EX_3 Measure Specification

Measure

Measure ID: PI_PHCDRR_3_PRE

Electronic Case Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_3_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_3_PROD

Electronic Case Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_3_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_4

Public Health Registry Reporting

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_4 Measure Specification

Measure

Measure ID: PI_PHCDRR_4_PRE

Public Health Registry Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_4_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_4_PROD

Public Health Registry Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_4_PROD Measure Specification

Measure

Measure ID: PI_PHCDRR_5

Clinical Data Registry Reporting

Public Health And Clinical Data ExchangeOptional

Review 2024 PI_PHCDRR_5 Measure Specification

Measure

Measure ID: PI_PHCDRR_5_PRE

Clinical Data Registry Reporting Active Engagement Level 1

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_5_PRE Measure Specification

Measure

Measure ID: PI_PHCDRR_5_PROD

Clinical Data Registry Reporting Active Engagement Level 2

Public Health And Clinical Data ExchangeRequired

Review 2024 PI_PHCDRR_5_PROD Measure Specification

Measure

Measure ID: PI_PPHI_1

Security Risk Analysis

Protect Patient Health InformationRequired

Review 2024 PI_PPHI_1 Measure Specification

Measure

Measure ID: PI_PPHI_2

SAFER Guides High Priority Practices Guide

Protect Patient Health InformationRequired

Review 2024 PI_PPHI_2 Measure Specification

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.
Population Health Measures (All MVPs)
QualityDescriptionCollection TypeSpecification(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

Download 2024 Q479 Measure Specifications (ZIP)

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

Download 2024 Q484 Measure Specifications (ZIP)