Medicare QPP

Physicians Advocacy Institute

These resources have not been updated since 2023 but the general details remain relevant. For a summary of the key changes for CY 2024, please click here.

Frequently Asked Questions Updated for 2023

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5. What if there are no applicable measures?

  1. There are 198 MIPS individual measures, across all specialties and settings, available for 2023 reporting. A list of all measures and a measures search tool that can help filter the measures by specialty are available on CMS’s QPP Resource Library in a zip file titled “Clinical Quality Measure Specifications Supporting Documents.” This zip folder will contain an excel file labeled “2023-Measure-List” that includes all CMS MIPS measures for 2023 reporting and includes step-by-step instructions for searching the list of measures. To view the additional measures that can be reported by QCDRs, which may offer more applicable measures based on specialty, condition, etc., please download the QCDR Measure Specifications file available on CMS’s QPP Resource Library.

    These measures specifications will provide a blueprint for each measure with detailed information such as the denominator criteria (patient population), numerator criteria (clinical action), documentation requirements (important for potential audits), and rationale with the evidence base and/or intent for the measure, among other key information.

    While more applicable, specialty-specific measures may be available for your practice, below are 6 measures that CMS has identified as cross-cutting measures that are broadly applicable regardless of specialty. However, you do not have to report on these measures if they do not apply to you or if you prefer to report on other measures. These measures include the following:

    Cross-Cutting Measures

    #47 - Care Plan
    #128 - Preventive Care & Screening: Body Mass Index (BMI) Screening & Follow-Up Plan
    #130 - Documentation of Current Medications in the Medical Record
    #226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
    #236 - Controlling High Blood Pressure
    #317 - Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
    As you evaluate which measures to report, these measures provide a good starting point. See the Appendix of PAI's Quality Category Overview where you will find the reporting specifications (extracted from official CMS measure specifications documents) for each of these measures for claims and registry reporting, along with flow-chart diagrams from CMS that walk you through the specifications and reporting.



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