2025 MIPS Quality Measure Changes

Every new MIPS year brings changes to the list of available quality measures. Below is a list of all MIPS quality measures that were added, deleted, or changed for the 2025 performance year in the 2025 Final Rule.

6 New Quality Measures – As part of scoring changes made in the 2022 final rule, these 6 measures will have a 7-point minimum score in their first year (2025) and a 5-point minimum in the second year (2026). These measures can score up to 10 points if there are enough submissions for CMS to calculate a performance period benchmark. The 5- and 7- point minimums apply only if data completeness is met, but case minimums do not apply, and even a 0% performance rate will earn the minimum points:

#506: Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy
#507: Appropriate Germline Testing for Ovarian Cancer Patients
#508: Adult COVID-19 Vaccination Status
#509: Melanoma: Tracking and Evaluation of Recurrence
#510: First Year Standardized Waitlist Ratio (FYSWR)
#511: Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)

As a reminder, the following measures were added in 2024, and therefore have a 5-point minimum score in 2025:

#495: Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood
#496: Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument
#497: Preventive Care and Wellness (composite)
#498: Connection to Community Service Provider
#499: Appropriate screening and plan of care for elevated intraocular pressure following intravitreal or periocular steroid therapy
#500: Acute posterior vitreous detachment appropriate examination and follow-up
#501: Acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow-up
#502: Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder
#503: Gains in Patient Activation Measure (PAM) Scores at 12 Months
#504: Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk
#505: Reduction in Suicidal Ideation or Behavior Symptoms
For users of specialty registries only, the following QCDR measures (see specifications here for which registries support these measures):
- AAD19: Psoriasis – Shared Decision Making in the Treatment of Psoriasis
- AAO37: Dysphonia: Laryngeal Examination
- AAO38: Thyroidectomy and Parathyroidectomy Nerve Injury
- AAO39: Neck Mass Evaluation
- ABFM13: Measuring the Value-Functions of Primary Care: Comprehensiveness of Care
- ACEP64: Avoidance of admission for adult patients in Emergency Department with low-risk Deep Vein Thrombosis (DVT).
- ACEP65: Appropriate Utilization of Imaging in rAAA (ruptured Abdominal Aortic Aneurysm) patients in Emergency Department
- ACEP66: Co-testing for HIV in high-risk patients in Emergency Department who are being tested for other sexually transmitted infections (STI) (Gonorrhea, Chlamydia, Syphilis or Trichomonas).
- AJRR12: Physical Health Outcomes in Total Hip and Knee Arthroplasty
- AQUA35: Non-Muscle Invasive Bladder Cancer: Initial Management/Surveillance for Non-Muscle Invasive Bladder Cancer
- AQUA36: Prostate Cancer: Confirmation Biopsy in Newly Diagnosed Patients on Active Surveillance
- CAP40: Squamous Cell Skin Cancer: Complete Reporting
- CAP41: Basal Cell Skin Cancer: Complete Reporting
- CAP42: Barrett’s Esophagus: Complete Analysis with Appropriate Consultation
- ECPR59: Patient Reported Trust in Provider
- GIQIC26: Screening Colonoscopy Adenoma Detection Rate
- HCPR25: Physician’s Orders for Life-Sustaining Treatment (POLST) Form
- HCPR26: Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD)
- HCPR27: Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) Placement
- IRIS61: Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery
- IRIS62: Regaining Vision After Cataract Surgery
- MSK1: Patients Suffering From a Neck Injury who Improve Physical Function
- MSK2: Patients Suffering From an Upper Extremity Injury who Improve Physical Function
- MSK3: Patients Suffering From a Back Injury who Improve Physical Function
- MSK4: Patients Suffering From a Lower Extremity Injury who Improve Physical Function
- MSK5: Patients Suffering From a Knee Injury who Improve Physical Function
- MSK6: Patients Suffering From a Neck Injury who Improve Pain
- MSK7: Patients Suffering From an Upper Extremity Injury who Improve Pain
- MSK8: Patients Suffering From a Back Injury who Improve Pain
- MSK9: Patients Suffering From a Lower Extremity Injury who Improve Pain
- MSK10: Patients Suffering From a Knee Injury who Improve Pain
- QMM26: Screening Abdominal Aortic Aneurysm Reporting with Recommendations
- QMM27: Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts
- QMM28: Reporting Breast Arterial Calcification (BAC) on Screening Mammography
- QMM29: Use of Appropriate Classification System for Lymphoma Specimen
- RCOIR14: Arteriovenous Fistula Patency Rate
- RCOIR15: Arteriovenous Graft Patency Rate
- THEPQR3: SGLT-2 inhibitors for patients with HFrEF with or without Type 2 Diabetes
- THEPQR4: Consultation to Palliative Care for Patients with End Stage Conditions
- USWR33: Diabetic Foot Ulcer (DFU) Healing or Closure
- USWR34: Venous Leg Ulcer (VLU) Healing or Closure
- USWR35: Adequate Off-loading of Diabetic Foot Ulcers performed at each visit, appropriate to location of ulcer
- USWR36: Pressure Ulcer* (PU) Healing or Closure (not on the lower extremity)

11 Removed Quality Measures

9 measures were removed entirely from the MIPS program:
- #104: Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
- #137: Melanoma: Continuity of Care – Recall System
- #254: Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
- #260: Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
  - Measure #344 has been revised to include CEA and can be a replacement measure, if not previously utilizing both measures
- #409: Clinical Outcome Post Endovascular Stroke Treatment
- #433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
  - Measure #432 has been revised to include bowel injuries and can be a replacement measure, if not previously utilizing both measures
- #439: Age Appropriate Screening Colonoscopy
- #452: Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Antiepidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
  - Review similar measure #451 for a possible replacement, if not previously utilizing both measures
- #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
2 measures had one collection type removed, while retaining another collection type:
- #019: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care:
  - The MIPS CQM specification was removed, but the eCQM was retained
- #155: Falls: Plan of Care:
  - The Part B Claims specification was removed, but the MIPS CQM was retained
1 measure was proposed for removal, but it was not finalized for 2025. However, it means this measure is likely to be removed in the near future:
- #144: Oncology: Medical and Radiation – Plan of Care for Pain

67 Measures with Substantive Changes

3 measures had significant changes that do not allow for performance comparisons to past years. This means that historical benchmarks will not be used to score these measures in 2025, and these measures will earn 0 points for large practices and 3 points for small practices, unless benchmarks can be established based on the 2025 data that is submitted (meaning this would be determined by CMS only after all data has been reported and final 2025 results have been released in summer 2026):
- #340: HIV Medical Visit Frequency
  - Numerator and denominator requirements were changed significantly. Review the full measure specification once released for changes.
- #344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
  - Renamed measure to “Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)”
  - Added CEA throughout the measure
- #432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
  - Added bowel injuries to this measure
  - Created separate performance rates for each type of injury
  - Renamed the measure “Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair”
20 measures had changes that CMS did not conclude were significant enough to remove historical benchmark scoring, but the changes may be of interest to clinicians and may affect how the measures are tracked and documented:
- #001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
  - The measure was revised to “Diabetes: Glycemic Status Assessment Greater Than 9%”
  - Added glucose management indicators (GMI) in addition to A1c
- #009: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  - The measure now specifies that “The communication of results…should be completed soon after the dilated exam is performed” (although “soon” is not defined)
- #168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
  - Additional complications were added to the numerator of this inverse measure
- #176: Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy
  - New biosimilar medications were added to the medication list
- #182: Functional Outcome Assessment
  - Revised to include standardized clinical assessment tools for patients unable to complete a questionnaire
- #185: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
  - Added an exclusion for patients who are unable to provide precise date or details of previous colonoscopies
- #238: Use of High-Risk Medications in Older Adults
  - The list of medications considered “high-risk” was updated
- #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  - Specific timeframes for follow-up screenings removed to allow clinician discretion in ordering follow-up
- #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
  - Numerator follow-up interval changed from “at least 10 years” to “10 years”
  - Added required documentation that the patient has received counseling and instruction on when a repeat colonoscopy should be scheduled
- #322: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
  - Added MUGA to the numerator of this inverse measure
- #336: Maternity Care: Postpartum Follow-up and Care Coordination
  - Added intimate partner violence screening to list of post-partum visit requirements
- #360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
  - Added infarct avid imaging to the measure denominator and studies that must be counted if previously performed
- #374: Closing the Referral Loop: Receipt of Specialist Report
  - Added denominator codes for psychology and neuropsychology
  - Added a written statement the the patient did not attend the referral appointment to the numerator met criteria
- #383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia
  - List of antipsychotic medications revised
- #413: Door to Puncture Time for Endovascular Stroke Treatment
  - Exclusion added for secondary stroke
- #448: Appropriate Workup Prior to Endometrial Ablation
  - Frequency changed from each procedure to once per year
- #488: Kidney Health Evaluation
  - Age range updated to 18-85 (from 18-75 previously)
- #490: Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors
  - Added Relatlimab and Tremelimumab
- #493: Adult Immunization Status
  - Pneumococcal vaccine age range updated to be all patients aged 19+ (from 65+ previously)
- #503: Gains in Patient Activation Measure (PAM®) Scores at 12 Months
  - Re-administration of survey changed from 6-12 months to 4-12 months after baseline
  - Follow-up survey minimum changed from 50% to 25%
10 measures were updated to include additional provider types and visits:
- #181: Elder Maltreatment Screen and Follow-Up Plan
  - Emergency department visits added as denominator-eligible encounters
- #282: Dementia: Functional Status Assessment
  - Added codes for speech language pathology and nuclear medicine for denominator inclusion
- #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
  - Added codes for speech language pathology and nuclear medicine for denominator inclusion
- #288: Dementia: Education and Support of Caregivers for Patients with Dementia
  - Added codes for speech language pathology and nuclear medicine for denominator inclusion
- #290: Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease
  - Added codes for neuropsychology and behavioral health for denominator inclusion
- #291: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease
  - Added codes for neuropsychology, behavioral health, and physical and occupational therapy for denominator inclusion
- #293: Rehabilitative Therapy Referral for Patients with Parkinson’s Disease
  - Added codes for neuropsychology, behavioral health, and speech language pathology for denominator inclusion
- #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  - Nutrition therapy encounter codes added for denominator inclusion
- #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
  - Updated denominator to include speech language pathology and nuclear medicine coding
- #498: Connection to Community Service Provider
  - Added coding for Dentistry, Emergency Medicine, Inpatient, Nuclear Medicine, Interventional Radiology, Psychiatry, Mental and Behavioral Health, Nephrology, Nutrition/Dietician, Obstetrics/Gynecology, Ophthalmology, Otolaryngology, Physical Therapy/Occupational Therapy, Home Care and Skilled Nursing
34 measures had changes to things like descriptions or definitions, but these changes were not significant enough to warrant removing the historical benchmark scoring, and most clinicians will not notice a difference in how the measures are tracked, reported, or scored:
- #009: Anti-Depressant Medication Management
- #047: Advance Care Plan
- #112 – MVP ONLY: Breast Cancer Screening
- #113 – MVP ONLY: Colorectal Cancer Screening
- #117: Diabetes: Eye Exam
- #130: Documentation of Current Medications in the Medical Record
- #177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
- #178: Rheumatoid Arthritis (RA): Functional Status Assessment
- #180: Rheumatoid Arthritis (RA): Glucocorticoid Management
- #236: Controlling High Blood Pressure
- #249: Barrett’s Esophagus
- #277: Sleep Apnea: Severity Assessment at Initial Diagnosis
- #281: Dementia: Cognitive Assessment
- #331: Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
- #355: Unplanned Reoperation within the 30-Day Postoperative Period
- #376: Functional Status Assessment for Total Hip Replacement
- #384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
- #393: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
- #418: Osteoporosis Management in Women Who Had a Fracture
- #420: Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
- #450: Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer
- #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
- #450: Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer
- #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
- #464: Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use
- #470: Functional Status After Primary Total Knee Replacement
- #485: Psoriasis – Improvement in Patient-Reported Itch Severity
- #486: Dermatitis – Improvement in Patient-Reported Itch Severity
- #490: Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors
- #492: Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System
- #497: Preventive Care and Wellness (composite)
- #500: Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up
- #501: Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up