Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for…
35%31 patients★★★★★2/55-star benchmark: 100%
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or…
23%31 patients★★★★★1/55-star benchmark: 100%
Breast Cancer Screening
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer
29%383 patients★★★★★2/55-star benchmark: 96%
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker…
17%1,401 patients★★★★★1/55-star benchmark: 100%
Colorectal Cancer Screening
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer
29%771 patients★★★★★2/55-star benchmark: 99%
Coronary Artery Disease (CAD): Antiplatelet Therapy
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel
62%426 patients★★★★★1/55-star benchmark: 100%
Diabetes: Eye Exam
Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period
27%244 patients★★★★★1/55-star benchmark: 100%
Diabetes: Medical Attention for Nephropathy
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
70%244 patients★★★★★3/55-star benchmark: 100%
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
99%6,399 patients★★★★★4/55-star benchmark: 100%
e-Prescribing
At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology.
73%74 patients★★★★★3/55-star benchmark: 100%
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
3%31 patients★★★★★1/55-star benchmark: 100%
Health Information Exchange
The MIPS eligible clinician that transitions or refers their patient to another setting of care or health care clinician (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving health care clinician for…
96%28 patients★★★★★4/55-star benchmark: 98%
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active…
55%510 patients★★★★★2/55-star benchmark: 100%
Medication Reconciliation
The MIPS eligible clinician performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS eligible clinician.
100%2,817 patients★★★★★5/55-star benchmark: 100%
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
1%371 patients★★★★★1/55-star benchmark: 100%
Patient-Specific Education
The MIPS eligible clinician must use clinically relevant information from CEHRT to identify patient-specific educational resources and provide access to those materials to at least one unique patient seen by the MIPS eligible clinician.
18%1,842 patients★★★★★1/55-star benchmark: 100%
Pneumococcal Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
52%1,394 patients★★★★★3/55-star benchmark: 95%
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous…
74%1,748 patients★★★★★3/55-star benchmark: 100%
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
46%124 patients★★★★★2/55-star benchmark: 100%
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
53%1,512 patients★★★★★3/55-star benchmark: 100%
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months
63%82 patients★★★★★1/55-star benchmark: 100%
Provide Patient Access
At least one patient seen by the MIPS eligible clinician during the performance period is provided timely access to view online, download, and transmit to a third party their health information subject to the MIPS eligible clinician's discretion to withhold…
97%1,842 patients★★★★★4/55-star benchmark: 100%
Quality of Life Assessment For Patients With Primary Headache Disorders
Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score…
24%25 patients★★★★★1/55-star benchmark: 100%
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months
50%22 patients★★★★★2/55-star benchmark: 100%
Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months
77%22 patients★★★★★3/55-star benchmark: 100%
Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >= 10 mg daily (or equivalent) with improvement or no change in disease…
50%22 patients★★★★★2/55-star benchmark: 100%
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months
50%22 patients★★★★★2/55-star benchmark: 100%
Screening for Osteoporosis for Women Aged 65-85 Years of Age
Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis
9%562 patients★★★★★1/55-star benchmark: 97%
Secure Messaging
For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of CEHRT to the patient (or the patient-authorized representative), or in response to a secure…
0%1,842 patients★★★★★1/55-star benchmark: 79%
Sleep Apnea: Assessment of Sleep Symptoms
Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness
2%115 patients★★★★★1/55-star benchmark: 100%
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
13%738 patients★★★★★1/55-star benchmark: 100%
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
4%56 patients