2026 MIPS Measure Directory

Every 2026 MIPS Quality measure, Improvement Activity and Promoting Interoperability measure in one place, with the official CMS specifications, 2026 benchmarks, scoring notes and plain-language guidance on what counts, what to pick and why a rate might be low. Maintained by ReportingMD, a CMS qualified registry and healthcare data pipe with a 100% submission rate since 2001.

205 Quality measures 95 Improvement Activities 39 Promoting Interoperability measures

Quality measures (205)

Listed by CMS measure number. Each page covers the denominator, numerator, exclusions, collection types, 2026 benchmarks and whether the measure is high priority, outcome or inverse.

Measure 001 Diabetes: Glycemic Status Assessment Greater Than 9% High priority, Outcome, Inverse
Measure 001SSP Diabetes: Glycemic Status Assessment Greater Than 9% High priority, Outcome, Inverse
Measure 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 006 Coronary Artery Disease (CAD): Antiplatelet Therapy
Measure 007 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)
Measure 008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Measure 009 Antidepressant Medication Management
Measure 012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Measure 019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care High priority
Measure 024 Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older High priority
Measure 039 Screening for Osteoporosis for Women Aged 65-85 Years of Age
Measure 047 Advance Care Plan High priority
Measure 048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Measure 050 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older High priority
Measure 052 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy
Measure 065 Appropriate Treatment for Upper Respiratory Infection (URI) High priority
Measure 066 Appropriate Testing for Pharyngitis High priority
Measure 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients High priority
Measure 112 Breast Cancer Screening
Measure 112SSP Breast Cancer Screening
Measure 113 Colorectal Cancer Screening
Measure 113SSP Colorectal Cancer Screening
Measure 116 Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis High priority
Measure 117 Diabetes: Eye Exam
Measure 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 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation
Measure 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear
Measure 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Measure 130 Documentation of Current Medications in the Medical Record High priority
Measure 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Measure 134SSP Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Measure 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care. High priority, Outcome
Measure 143 Oncology: Medical and Radiation - Pain Intensity Quantified High priority
Measure 144 Oncology: Medical and Radiation - Plan of Care for Pain High priority
Measure 145 Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy High priority
Measure 155 Falls: Plan of Care High priority
Measure 164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation High priority, Outcome, Inverse
Measure 167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure High priority, Outcome, Inverse
Measure 168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration High priority, Outcome, Inverse
Measure 176 Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy
Measure 177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Measure 178 Rheumatoid Arthritis (RA): Functional Status Assessment
Measure 180 Rheumatoid Arthritis (RA): Glucocorticoid Management
Measure 181 Elder Maltreatment Screen and Follow-Up Plan High priority
Measure 182 Functional Outcome Assessment High priority
Measure 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Measure 191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery High priority, Outcome
Measure 205 Sexually Transmitted Infection (STI) Testing for People with HIV
Measure 217 Functional Status Change for Patients with Knee Impairments High priority, Outcome
Measure 218 Functional Status Change for Patients with Hip Impairments High priority, Outcome
Measure 219 Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments High priority, Outcome
Measure 220 Functional Status Change for Patients with Low Back Impairments High priority, Outcome
Measure 221 Functional Status Change for Patients with Shoulder Impairments High priority, Outcome
Measure 222 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments High priority, Outcome
Measure 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Measure 236 Controlling High Blood Pressure High priority, Outcome
Measure 236SSP Controlling High Blood Pressure High priority, Outcome
Measure 238 Use of High-Risk Medications in Older Adults High priority, Inverse
Measure 239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
Measure 240 Childhood Immunization Status
Measure 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting High priority
Measure 249 Barrett's Esophagus
Measure 250 Radical Prostatectomy Pathology Reporting
Measure 259 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) High priority, Outcome
Measure 261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness High priority
Measure 268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
Measure 275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
Measure 277 Sleep Apnea: Severity Assessment at Initial Diagnosis
Measure 279 Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.
Measure 281 Dementia: Cognitive Assessment
Measure 282 Dementia: Functional Status Assessment
Measure 286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia High priority
Measure 288 Dementia: Education and Support of Caregivers for Patients with Dementia High priority
Measure 291 Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease
Measure 293 Rehabilitative Therapy Referral for Patients with Parkinson's Disease High priority
Measure 303 Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery High priority, Outcome
Measure 304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery High priority
Measure 305 Initiation and Engagement of Substance Use Disorder Treatment High priority
Measure 309 Cervical Cancer Screening
Measure 310 Chlamydia Screening in Women
Measure 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Measure 318 Falls: Screening for Future Fall Risk High priority
Measure 320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients High priority
Measure 321 CAHPS for MIPs Clinician/Group Survey High priority
Measure 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Measure 331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) High priority, Inverse
Measure 332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) High priority
Measure 335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) High priority, Outcome, Inverse
Measure 336 Maternity Care: Postpartum Follow-up and Care Coordination High priority
Measure 338 HIV Viral Suppression High priority, Outcome
Measure 340 HIV Annual Retention in Care High priority
Measure 344 Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) High priority, Outcome
Measure 350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy High priority
Measure 351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation High priority
Measure 354 Anastomotic Leak Intervention High priority, Outcome, Inverse
Measure 355 Unplanned Reoperation within the 30-Day Postoperative Period High priority, Outcome, Inverse
Measure 356 Unplanned Hospital Readmission within 30 Days of Principal Procedure High priority, Outcome, Inverse
Measure 357 Surgical Site Infection (SSI) High priority, Outcome, Inverse
Measure 358 Patient-Centered Surgical Risk Assessment and Communication High priority
Measure 360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies High priority
Measure 364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines High priority
Measure 366 Follow-Up Care for Children Prescribed ADHD Medication
Measure 370 Depression Remission at Twelve Months High priority, Outcome
Measure 374 Closing the Referral Loop: Receipt of Specialist Report High priority
Measure 376 Functional Status Assessment for Total Hip Replacement High priority
Measure 377 Functional Status Assessments for Heart Failure High priority
Measure 378 Children Who Have Dental Decay or Cavities High priority, Outcome, Inverse
Measure 379 Primary Caries Prevention Intervention as Offered by Dentists
Measure 382 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment High priority
Measure 383 Adherence to Antipsychotic Medications For Individuals with Schizophrenia High priority, Outcome
Measure 384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery High priority, Outcome
Measure 385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery High priority, Outcome
Measure 386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences High priority
Measure 387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Measure 389 Cataract Surgery: Difference Between Planned and Final Refraction High priority, Outcome
Measure 392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation High priority, Outcome, Inverse
Measure 393 Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision High priority, Outcome, Inverse
Measure 394 Immunizations for Adolescents
Measure 395 Lung Cancer Reporting (Biopsy/Cytology Specimens) High priority
Measure 396 Lung Cancer Reporting (Resection Specimens) High priority
Measure 397 Melanoma Reporting High priority
Measure 398 Optimal Asthma Control High priority, Outcome
Measure 400 One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation
Measure 401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Measure 404 Anesthesiology Smoking Abstinence High priority, Outcome
Measure 405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions High priority
Measure 406 Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients High priority, Inverse
Measure 410 Psoriasis: Clinical Response to Systemic Medications High priority, Outcome
Measure 413 Door to Puncture Time for Endovascular Stroke Treatment High priority, Outcome
Measure 415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older High priority
Measure 416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years High priority, Inverse
Measure 418 Osteoporosis Management in Women Who Had a Fracture
Measure 420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey High priority, Outcome
Measure 421 Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
Measure 422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury High priority
Measure 430 Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy High priority
Measure 431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Measure 432 Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair High priority, Outcome, Inverse
Measure 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Measure 440 Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician High priority
Measure 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) High priority, Outcome
Measure 445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) High priority, Outcome, Inverse
Measure 448 Appropriate Workup Prior to Endometrial Ablation High priority
Measure 450 Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer High priority
Measure 451 RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
Measure 453 Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) High priority, Inverse
Measure 457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better) High priority, Inverse
Measure 459 Back Pain After Lumbar Surgery High priority, Outcome
Measure 461 Leg Pain After Lumbar Surgery High priority, Outcome
Measure 462 Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
Measure 463 Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) High priority
Measure 464 Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use High priority
Measure 465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries High priority
Measure 468 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) High priority
Measure 470 Functional Status After Primary Total Knee Replacement High priority, Outcome
Measure 471 Functional Status After Lumbar Surgery High priority, Outcome
Measure 475 HIV Screening
Measure 476 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia High priority, Outcome
Measure 477 Multimodal Pain Management High priority
Measure 478 Functional Status Change for Patients with Neck Impairments High priority, Outcome
Measure 479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups High priority, Outcome, Inverse
Measure 480 Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS) High priority, Outcome, Inverse
Measure 481 Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer High priority
Measure 482 Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate High priority, Outcome, Inverse
Measure 483 Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) High priority, Outcome
Measure 484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC) High priority, Outcome, Inverse
Measure 485 Psoriasis - Improvement in Patient-Reported Itch Severity High priority, Outcome
Measure 486 Dermatitis – Improvement in Patient-Reported Itch Severity High priority, Outcome
Measure 488 Kidney Health Evaluation
Measure 489 Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy
Measure 490 Appropriate Intervention of Immune-related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors
Measure 491 Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status High priority
Measure 492 Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System High priority, Outcome, Inverse
Measure 493 Adult Immunization Status
Measure 494 Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level) High priority, Outcome, Inverse
Measure 495 Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood High priority, Outcome
Measure 496 Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument
Measure 497 Preventive Care and Wellness (composite)
Measure 499 Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy
Measure 500 Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up
Measure 501 Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up
Measure 502 Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder High priority, Outcome
Measure 503 Gains in Patient Activation Measure (PAM®) Scores at 12 Months High priority, Outcome
Measure 504 Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk High priority
Measure 505 Reduction in Suicidal Ideation or Behavior Symptoms High priority, Outcome
Measure 506 Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy High priority
Measure 507 Appropriate Germline Testing for Ovarian Cancer Patients
Measure 509 Melanoma: Tracking and Evaluation of Recurrence High priority
Measure 510 First Year Standardized Kidney Transplant Waitlist Ratio (FYSWR)
Measure 511 Percentage of Prevalent Patients Waitlisted for Kidney Transplant (PPPW) and Percentage of Prevalent Patients Waitlisted for Kidney Transplant in Active Status (aPPPW)
Measure 512 Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR)
Measure 513 Patient Reported Falls and Plan of Care High priority
Measure 514 Diagnostic Delay of Venous Thromboembolism in Primary Care High priority, Outcome, Inverse
Measure 515 Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes
Measure 516 Hepatitis C Virus (HCV): Sustained Virological Response (SVR) High priority, Outcome
Measure CAHPS_1 CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information High priority
Measure CAHPS_11 CAHPS for MIPS SSM: Stewardship of Patient Resources High priority
Measure CAHPS_2 CAHPS for MIPS SSM: How Well Providers Communicate High priority
Measure CAHPS_3 CAHPS for MIPS SSM: Patient’s Rating of Provider High priority
Measure CAHPS_4 CAHPS for MIPS SSM: Access to Specialists High priority
Measure CAHPS_5 CAHPS for MIPS SSM: Health Promotion and Education High priority
Measure CAHPS_6 CAHPS for MIPS SSM: Shared Decision Making High priority
Measure CAHPS_7 CAHPS for MIPS SSM: Health Status and Functional Status High priority
Measure CAHPS_8 CAHPS for MIPS SSM: Care Coordination High priority
Measure CAHPS_9 CAHPS for MIPS SSM: Courteous and Helpful Office Staff High priority

Improvement Activities (95)

Listed by activity ID. Each page covers the CMS description, subcategory, how to attest and what documentation to keep.

IA_AHW_1 Chronic Care and Preventative Care Management for Empaneled Patients Achieving Health Equity
IA_BE_1 Use of certified EHR to capture patient reported outcomes Beneficiary Engagement
IA_BE_12 Use evidence-based decision aids to support shared decision-making. Beneficiary Engagement
IA_BE_14 Engage Patients and Families to Guide Improvement in the System of Care Beneficiary Engagement
IA_BE_15 Engagement of Patients, Family, and Caregivers in Developing a Plan of Care Beneficiary Engagement
IA_BE_16 Promote Self-management in Usual Care Beneficiary Engagement
IA_BE_19 Use group visits for common chronic conditions (e.g., diabetes). Beneficiary Engagement
IA_BE_22 Improved Practices that Engage Patients Pre-Visit Beneficiary Engagement
IA_BE_23 Integration of patient coaching practices between visits Beneficiary Engagement
IA_BE_24 Financial Navigation Program Beneficiary Engagement
IA_BE_25 Drug Cost Transparency Beneficiary Engagement
IA_BE_26 Promote Use of Patient-Reported Outcome Tools Beneficiary Engagement
IA_BE_27 Comprehensive Eye Exams Beneficiary Engagement
IA_BE_3 Engagement with QIN-QIO to implement self-management training programs Beneficiary Engagement
IA_BE_4 Engagement of Patients through Implementation of New Patient Portal Beneficiary Engagement
IA_BE_5 Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities Beneficiary Engagement
IA_BE_6 Regularly Assess Patient Experience of Care and Follow Up on Findings Beneficiary Engagement
IA_BMH_1 Antipsychotic-Medication-Associated Physical Health Condition Assessment and Monitoring Behavioral and Mental Health
IA_BMH_10 Completion of Collaborative Care Management Training Program Behavioral and Mental Health
IA_BMH_11 Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice Behavioral and Mental Health
IA_BMH_12 Promoting Clinician Well-Being Behavioral and Mental Health
IA_BMH_14 Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women Behavioral and Mental Health
IA_BMH_15 Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults Behavioral and Mental Health
IA_BMH_2 Tobacco use Behavioral and Mental Health
IA_BMH_4 Depression screening Behavioral and Mental Health
IA_BMH_5 MDD prevention and treatment interventions Behavioral and Mental Health
IA_BMH_7 Implementation of Integrated Patient Centered Behavioral Health Model Behavioral and Mental Health
IA_BMH_9 Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients Behavioral and Mental Health
IA_CC_10 Care transition documentation practice improvements Care Coordination
IA_CC_11 Care transition standard operational improvements Care Coordination
IA_CC_12 Care coordination agreements that promote improvements in patient tracking across settings Care Coordination
IA_CC_13 Practice Improvements to Align with OpenNotes Principles Care Coordination
IA_CC_15 PSH Care Coordination Care Coordination
IA_CC_16 Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients Care Coordination
IA_CC_17 Patient Navigator Program Care Coordination
IA_CC_18 Relationship-Centered Communication Care Coordination
IA_CC_19 Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes. Care Coordination
IA_CC_7 Regular training in care coordination Care Coordination
IA_CC_8 Implementation of documentation improvements for practice/process improvements Care Coordination
IA_CC_9 Implementation of practices/processes for developing regular individual care plans Care Coordination
IA_EPA_2 Use of telehealth services that expand practice access Expanded Practice Access
IA_EPA_3 Collection and use of patient experience and satisfaction data on access Expanded Practice Access
IA_EPA_4 Additional improvements in access as a result of QIN/QIO TA Expanded Practice Access
IA_EPA_5 Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/) Expanded Practice Access
IA_EPA_6 Create and Implement a Language Access Plan Expanded Practice Access
IA_EPA_7 Enhance Engagement of Medicaid and Other Underserved Populations Expanded Practice Access
IA_EPA_8 Provide Education Opportunities for New Clinicians Expanded Practice Access
IA_ERP_1 Participation on Disaster Medical Assistance Team, registered for 6 months. Emergency Response and Preparedness
IA_ERP_2 Participation in a 60-day or greater effort to support domestic or international humanitarian needs. Emergency Response and Preparedness
IA_MVP Practice-Wide Quality Improvement in MIPS Value Pathways Other
IA_PCMH Electronic submission of Patient Centered Medical Home accreditation Other
IA_PM_11 Regular review practices in place on targeted patient population needs Population Management
IA_PM_14 Implementation of methodologies for improvements in longitudinal care management for high risk patients Population Management
IA_PM_15 Implementation of episodic care management practice improvements Population Management
IA_PM_16 Implementation of medication management practice improvements Population Management
IA_PM_17 Participation in Population Health Research Population Management
IA_PM_18 Provide Clinical-Community Linkages Population Management
IA_PM_19 Glycemic Screening Services Population Management
IA_PM_2 Anticoagulant Management Improvements Population Management
IA_PM_20 Glycemic Referring Services Population Management
IA_PM_21 Advance Care Planning Population Management
IA_PM_22 Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services Population Management
IA_PM_23 Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines Population Management
IA_PM_24 Implementation of Protocols and Provision of Resources to Increase Lung Cancer Screening Uptake Population Management
IA_PM_25 Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk Population Management
IA_PM_27 Improving Detection of Cognitive Impairment in Primary Care Population Management
IA_PM_28 Integrating Oral Health Care in Primary Care Population Management
IA_PM_3 RHC, IHS or FQHC quality improvement activities Population Management
IA_PM_4 Glycemic management services Population Management
IA_PM_5 Engagement of community for health status improvement Population Management
IA_PSPA_1 Participation in an AHRQ-listed patient safety organization. Patient Safety and Practice Assessment
IA_PSPA_12 Participation in private payer CPIA Patient Safety and Practice Assessment
IA_PSPA_13 Participation in Joint Commission Evaluation Initiative Patient Safety and Practice Assessment
IA_PSPA_15 Implementation of an ASP Patient Safety and Practice Assessment
IA_PSPA_16 Use decision support, ideally platform-agnostic, interoperable clinical decision support (CDS) tools, and standardized treatment protocols to manage workflow on the care team to meet patient needs. Patient Safety and Practice Assessment
IA_PSPA_17 Implementation of analytic capabilities to manage total cost of care for practice population Patient Safety and Practice Assessment
IA_PSPA_18 Measurement and improvement at the practice and panel level Patient Safety and Practice Assessment
IA_PSPA_19 Implementation of formal quality improvement methods, practice changes, or other practice improvement processes Patient Safety and Practice Assessment
IA_PSPA_2 Participation in MOC Part IV Patient Safety and Practice Assessment
IA_PSPA_21 Implementation of fall screening and assessment programs Patient Safety and Practice Assessment
IA_PSPA_22 CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain Patient Safety and Practice Assessment
IA_PSPA_23 Completion of CDC Training on Antibiotic Stewardship Patient Safety and Practice Assessment
IA_PSPA_25 Cost Display for Laboratory and Radiographic Orders Patient Safety and Practice Assessment
IA_PSPA_26 Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event Patient Safety and Practice Assessment
IA_PSPA_28 Completion of an Accredited Safety or Quality Improvement Program Patient Safety and Practice Assessment
IA_PSPA_3 Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity Patient Safety and Practice Assessment
IA_PSPA_31 Patient Medication Risk Education Patient Safety and Practice Assessment
IA_PSPA_32 Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support Patient Safety and Practice Assessment
IA_PSPA_33 Application of CDC’s Training for Healthcare Providers on Lyme Disease Patient Safety and Practice Assessment
IA_PSPA_34 Patient Safety in Use of Artificial Intelligence (AI) Patient Safety and Practice Assessment
IA_PSPA_35 Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data Patient Safety and Practice Assessment
IA_PSPA_4 Administration of the AHRQ Survey of Patient Safety Culture Patient Safety and Practice Assessment
IA_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements Patient Safety and Practice Assessment
IA_PSPA_8 Use of Patient Safety Tools Patient Safety and Practice Assessment
IA_PSPA_9 Completion of the AMA STEPS Forward program Patient Safety and Practice Assessment

Promoting Interoperability measures (39)

Listed by measure ID. Each page covers the objective, whether the measure is required, a bonus or an exclusion, and how to meet it.

PI_EP_1 e-Prescribing Electronic Prescribing
PI_EP_2 Query of the Prescription Drug Monitoring Program (PDMP) Electronic Prescribing
PI_EP_2_EX_1 Query of the Prescription Drug Monitoring Program (PDMP) Exclusion Electronic Prescribing
PI_EP_2_EX_2 Query of the Prescription Drug Monitoring Program (PDMP) Exclusion Electronic Prescribing
PI_HIE_1 Support Electronic Referral Loops By Sending Health Information Health Information Exchange
PI_HIE_4 Support Electronic Referral Loops By Receiving and Reconciling Health Information Health Information Exchange
PI_HIE_5 Health Information Exchange (HIE) Bi-Directional Exchange Health Information Exchange
PI_HIE_6 Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM) Health Information Exchange
PI_INFBLO_1 Actions to Limit or Restrict the Compatibility of CEHRT Attestation
PI_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion Health Information Exchange
PI_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion Health Information Exchange
PI_LVPP_1 e-Prescribing Exclusion Electronic Prescribing
PI_ONCACB_1 ONC-ACB Surveillance Attestation Attestation
PI_ONCDIR_1 ONC Direct Review Attestation Attestation
PI_PEA_1 Provide Patients Electronic Access to Their Health Information Provider to Patient Exchange
PI_PHCDRR_1 Immunization Registry Reporting Public Health and Clinical Data Exchange
PI_PHCDRR_1_EX_1 Immunization Registry Reporting Exclusion Public Health and Clinical Data Exchange
PI_PHCDRR_1_EX_2 Immunization Registry Reporting Exclusion Public Health and Clinical Data Exchange
PI_PHCDRR_1_EX_3 Immunization Registry Reporting Exclusion Public Health and Clinical Data Exchange
PI_PHCDRR_1_PRE Immunization Registry Reporting Active Engagement Level 1 Public Health and Clinical Data Exchange
PI_PHCDRR_1_PROD Immunization Registry Reporting Active Engagement Level 2 Public Health and Clinical Data Exchange
PI_PHCDRR_2 Syndromic Surveillance Reporting Public Health and Clinical Data Exchange
PI_PHCDRR_2_PRE Syndromic Surveillance Reporting Active Engagement Level 1 Public Health and Clinical Data Exchange
PI_PHCDRR_2_PROD Syndromic Surveillance Reporting Active Engagement Level 2 Public Health and Clinical Data Exchange
PI_PHCDRR_3 Electronic Case Reporting Public Health and Clinical Data Exchange
PI_PHCDRR_3_EX_1 Electronic Case Reporting Exclusion Public Health and Clinical Data Exchange
PI_PHCDRR_3_EX_2 Electronic Case Reporting Exclusion Public Health and Clinical Data Exchange
PI_PHCDRR_3_EX_3 Electronic Case Reporting Exclusion Public Health and Clinical Data Exchange
PI_PHCDRR_3_PRE Electronic Case Reporting Active Engagement Level 1 Public Health and Clinical Data Exchange
PI_PHCDRR_3_PROD Electronic Case Reporting Active Engagement Level 2 Public Health and Clinical Data Exchange
PI_PHCDRR_4 Public Health Registry Reporting Public Health and Clinical Data Exchange
PI_PHCDRR_4_PRE Public Health Registry Reporting Active Engagement Level 1 Public Health and Clinical Data Exchange
PI_PHCDRR_4_PROD Public Health Registry Reporting Active Engagement Level 2 Public Health and Clinical Data Exchange
PI_PHCDRR_5 Clinical Data Registry Reporting Public Health and Clinical Data Exchange
PI_PHCDRR_5_PRE Clinical Data Registry Reporting Active Engagement Level 1 Public Health and Clinical Data Exchange
PI_PHCDRR_5_PROD Clinical Data Registry Reporting Active Engagement Level 2 Public Health and Clinical Data Exchange
PI_PHCDRR_6 Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM) Public Health and Clinical Data Exchange
PI_PPHI_1 Security Risk Analysis Protect Patient Health Information
PI_PPHI_2 High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide Protect Patient Health Information

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