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MIPS Measures Relevant to Orthopedic Surgery

Quality (50% of total score) - Select 6 measures including one Outcome measure (or high priority measure if an outcome measure is not applicable) and report each on 60% of eligible Medicare and non-Medicare patient/visits for the entire year. Suggestions for your specialty include but are not limited to the following:

#21 Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin* - High Priority
#23 Venous Thromboembolism (VTE) Prophlyaxis (When Indicated in ALL Patients)* - High Priority
#24 Communication with the physician managing ongoing care post-fracture*
#39 Screening or therapy for osteoporosis for women aged 65 years and older
#46 Medication Reconciliation* - High Priority
#47 Care Plan* - High Priority
#109 Function and pain assessment* - High Priority
#110 Preventive Care and Screening: Influenza Immunization
#128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan*
#130 Documentation of Current Medications in the Medical Record* - High Priority
#131 Pain Assessment and Follow-Up* - High Priority
#134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan*
#154 Falls: Risk Assessment* - High Priority
#155 Falls: Plan of Care*- High Priority
#178 Rheumatoid Arthritis (RA): Functional Status Assessment*
#179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis*
#180 Rheumatoid Arthritis (RA): Glucocorticoid Management*
#226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention*
#317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented*
#350 Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy* -High Priority
#351 Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation* -High Priority
#352 Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet* -High Priority
#353 Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report* -High Priority
#358 Patient-Centered Surgical Risk Assessment and Communication* -High Priority
#374 Closing the Referral Loop: Receipt of Specialist Report* -High Priority
#402 Tobacco Use and Help with Quitting Among Adolescents*
#408 Opioid Therapy Follow-up Evaluation*
#412 Documentation of Signed Opioid Treatment Agreement *
#414 Evaluation or Interview for Risk of Opioid Misuse *
#418 Osteoporosis Management in Women Who Had a Fracture*
#459 Average Change in Back Pain following Lumbar Discectomy / Laminotomy* - Outcome
#460 Average Change in Back Pain following Lumbar Fusion* - Outcome
#461 Average Change in Leg Pain following Lumbar Discectomy / Laminotomy* - Outcome

BOLD - Only OUTCOME measures beyond our 6 QCDR measures

ACI: Advancing Care Information (25% of total score) - Replaces the Medicare EHR Incentive Program also known as Meaningful Use. A minimum of the following base measures are required if reporting this category. Note that EHR's certified to a 2014 edition report a different set of measures.
Conduct security risk analysis
Provide patient electronic access
Send a summary of care
Receive/accept a summary of care

IA: Improvement Activities (15% of total score) - Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with fewer than 15 participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days. There are over 90 possible measures to choose from. The following are suggestions only:
Collection and use of patient experience and satisfaction data on access (medium weighted).
Annual registration in the Prescription Drug Monitoring Program (medium weighted).
Engagement of new Medicaid patients and follow-up (high weighted).
Engage patients and families to guide improvement in the system of care (medium weighted).
Implementation of documentation improvements for practice/process improvements (medium weighted).
Implementation of improvements that contribute to more timely communication of test results(medium weighted).