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 2023 performance year in the 2023 Final Rule.
Click the link in the measure title to see the final rule description for new, changed, or deleted measures (tip: skip directly to the section titled “Rationale” for a summary of the measure changes and why they are being made).
9 New Quality Measures – As part of scoring changes made in the 2022 final rule, these 9 measures will have a 7-point minimum score in their first year (2023) and a 5-point minimum in the second year (2024).
- #485: Psoriasis – Improvement in Patient-Reported Itch Severity [page 2]
- #486: Dermatitis – Improvement in Patient-Reported Itch Severity
- #487: Screening for Social Drivers of Health [page 2] [page 3] [page 4] [page 5] [page 6] [page 7]
- #488: Kidney Health Evaluation [page 2]
- #489: Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy
- #490: Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors
- #491: Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma [page 2]
- #492: Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System (Administrative Claims-based Measure) [page 2] [page 3] [page 4] [page 5] [page 6]
- #493: Adult Immunization Status [page 2] [page 3]
As a reminder, the following measures were added in 2022, and therefore have a 5-point minimum score in 2023:
- #481: Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer
- #482: Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate
- #483: Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
13 Removed Quality Measures
- 11 measures were removed entirely from the MIPS program:
- #076: Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
- #119: Diabetes: Medical Attention for Nephropathy – the new measure #488 may serve as a replacement for some providers
- #258: Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)
- #265: Biopsy Follow-Up – while not related clinically, most dermatologists reporting this measure could report the new measures #485 and/or #486
- #323: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
- #375: Functional Status Assessment for Total Knee Replacement – measure #470 is suggested as a replacement by CMS
- #425: Photodocumentation of Cecal Intubation
- #455: Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)
- #460: Back Pain After Lumbar Fusion
- 2 measures were removed from traditional MIPS, but were retained for use in current and future MVPs (MIPS Value Pathways)
- 3 measures were removed only from part B claims reporting due to being topped-out:
- #117: Diabetes: Eye Exam – retained as a MIPS CQM and eCQM; note measure changes below as well.
- #130: Documentation of Current Medications in the Medical Record – retained as a MIPS CQM and eCQM; note measure changes below as well.
- #416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years – retained as a MIPS CQM
- 4 measures were proposed for removal, but these removals were not finalized for 2023. These are important to note, as it may indicate a short lifespan for these measures. They may be on the radar for removal in future years:
- #260: Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
- #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
- #275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
- #439: Age Appropriate Screening Colonoscopy
74 Measures with Substantive Changes
- 5 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 2023, and these measures will earn zero points for large practices and 3 points for small practices, unless benchmarks can be established based on the 2023 data that is submitted (meaning this would be determined by CMS only after all data has been reported and final 2023 results have been released in summer 2024):
- #145: Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
- #277: Sleep Apnea: Severity Assessment at Initial Diagnosis
- #459: Back Pain After Lumbar Discectomy/Laminectomy [page 2]
- #461: Leg Pain After Lumbar Discectomy/Laminectomy [page 2]
- #471: Functional Status After Lumbar Discectomy/Laminectomy [page 2]
- 11 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:
- #113: Colorectal Cancer Screening [page 2]
- The age range for this measure was changed to 45-75 (previously it was 50-75).
- #130: Documentation of Current Medications in the Medical Record
- “Cannabis/cannabidiol products” was added to the list of items that should be assessed when reviewing or updating the current medication list.
- #176: Tuberculosis Screening Prior to First Course Biologic Therapy [page 2]
- CMS has expanded the medications included in this measure. The 2022 measure specified only biologics classified as DMARD therapy, but the 2023 measure has broadened this to include “a biologic and/or immune response modifier.”
- Drugs with the brand names Cyltezo, Amjevita, Siliq, Skyrizi, and Ilumya were also added to the included medication list.
- #181: Elder Maltreatment Screen and Follow-Up Plan
- The age range for this measure was lowered to 60 and older (previously it was 65 and older).
- #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy
- The timeliness of IV thrombolytic intervention was changed to align with current guidelines.
- The 2023 measure reads “Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic was initiated within 4.5 hours of time last known well.” (Previously it was: “Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV alteplase was initiated within three hours of time last known well.”)
- #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention [page 2] [page 3]
- Vape products and e-cigarettes are now explicitly included in the definition of “Tobacco Use.” Previous guidance was to exclude these products as they were nicotine products, not tobacco products, but the 2023 definition includes all forms of tobacco and other nicotine products.
- The lookback period for counseling was changed from “on the date of the encounter or within the previous 12 months” to “during the measurement period or in the six months prior to the measurement period.”
- #320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
- The age range for this measure was changed to 45-75 (previously it was 50-75).
- #374: Closing the Referral Loop: Receipt of Specialist Report
- Language was added to clarify that only the first referral of the year for any patient should be counted (this is not new, but is apparently receiving renewed focus)
- Only referrals made on or before October 31 will be included in the measure going forward to allow sufficient time to receive the consultant report back before reporting MIPS data.
- #378: Children Who Have Dental Decay or Cavities
- Language has been added to ensure this measure is reported only by dentists.
- #379: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
- Language has been added to ensure this measure is reported only by dentists.
- #439: Age Appropriate Screening Colonoscopy
- The denominator has been updated to include colonoscopies on patients 45 or older (previously was 50 or older)
- #113: Colorectal Cancer Screening [page 2]
- 58 measures had changes to things like descriptions or definitions, but these changes were not significant enough to warrant removing the historical benchmark scoring for 2023, and most clinicians will not notice a difference in how the measures are tracked, reported, or scored:
- #1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) [page 2]
- #5: 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) [page 2]
- #6: Coronary Artery Disease (CAD): Antiplatelet Therapy
- #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) [page 2]
- #8: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) [page 2]
- #9: Anti-Depressant Medication Management
- #12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
- #19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
- #39: Screening for Osteoporosis for Women Aged 65-85 Years of Age
- #50: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
- #65: Appropriate Treatment for Upper Respiratory Infection (URI)
- #66: Appropriate Testing for Pharyngitis
- #107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
- #112: Breast Cancer Screening
- #116: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
- #117: Diabetes: Eye Exam
- #118: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
- #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan [page 2]
- #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- #143: Oncology: Medical and Radiation – Pain Intensity Quantified
- #182: Functional Outcome Assessment
- #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
- #217: Functional Status Change for Patients with Knee Impairments
- #218: Functional Status Change for Patients with Hip Impairments
- #219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
- #220: Functional Status Change for Patients with Low Back Impairments
- #221: Functional Status Change for Patients with Shoulder Impairments
- #222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
- #236: Controlling High Blood Pressure
- #238: Use of High-Risk Medications in Older Adults [page 2]
- #239: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
- #240: Childhood Immunization Status [page 2]
- #293: Rehabilitative Therapy Referral for Patients with Parkinson’s Disease
- #305: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment [page 2]
- #309: Cervical Cancer Screening
- #310: Chlamydia Screening for Women
- #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
- #318: Falls: Screening for Future Fall Risk
- #321: CAHPS for MIPS Clinician/Group Survey (CMS-approved Survey Vendor measure only)
- #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
- #366: Follow-Up Care for Children Prescribed ADHD Medication (ADD)
- #370: Depression Remission at Twelve Months
- #376: Functional Status Assessment for Total Hip Replacement
- #377: Functional Status Assessments for Heart Failure
- #394: Immunizations for Adolescents
- #418: Osteoporosis Management in Women Who Had a Fracture
- #431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
- #438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
- #440: Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician [page 2]
- #441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
- #453: Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)
- #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy Category Description
- #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
- #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture [page 2]
- #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
- #478: Functional Status Change for Patients with Neck Impairments
- #481: Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer