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:
- You must select 4 quality measures from the list below
- At least 1 measure must be an outcome measure
- If no outcome measures are available, you may report a high priority measure.
- 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.
Measure | Measure Description | Collection Type | Specification(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)Activity | Activity Description | Activity 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:
- 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: 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)