2024 MIPS Final Rule

2024 MIPS Final Rule

In November, CMS released the 2024 Final Rule for MIPS reporting. While not all proposed changes were accepted in the final rule, there are notable updates which may affect how practices report. These changes were made for traditional MIPS reporting as well as APMs, ACOs and the MVP reporting track. While wrapping up your 2023 reporting year, it will be important to begin creating a 2024 plan for your practice and make any modifications to workflows or documentation methods. 

Traditional MIPS

Quality

CMS has raised the Data Completeness minimum from 70% to 75%. It will remain at 75% through at least the 2026 reporting year, but they may propose to raise it to 80% for the 2027 reporting year. It should be a priority from the beginning of the year to capture MIPS data.

There will be 11 new Quality measures in 2024:

Quality Measure AddedCollection Type
#495 Ambulatory Palliative Care Patients’ Experience of Feeling Heard and UnderstoodMIPS CQM
#496 Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized InstrumentMIPS CQM
#499 Preventative Care and Wellness (composite)MIPS CQM
#500 Connection to Community Service Provider MIPS CQM
#501 Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy MIPS CQM
#502 Acute Posterior Vitreous Detachment Appropriate Examination and Follow-UpMIPS CQM
#503 Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-UpMIPS CQM
#504 Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use DisorderMIPS CQM
#505 Gains in Patient Activation Measure (PAM) Scores at 12 Months MIPS CQM
#506 Initiation, Review, And/Or Update to Suicide Safety Plan for Individuals With Suicidal Thoughts, Behavior or Suicide RiskMIPS CQM
#507 Reduction in Suicidal Ideation or Behavior Symptoms MIPS CQM

**For the Preventative Care and Wellness (composite) measure you will need to document the following measures: Preventative Care and Screening: Influenza Immunization, Pneumococcal Vaccination Status for Older Adults, Breast Cancer Screening, Colorectal Cancer Screening, Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan, Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention, and Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented.

There are 11 Quality measures which will be removed:

Quality Measures RemovedCollection Type
#14 Age-Related Macular Degeneration (AMD): Dilated Macular ExaminationMIPS CQM
#93 Acute Otitis Externa (AOE) Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseMIPS CQM
#107 Adult Major Depressive Disorder (MDD): Suicide Risk AssessmenteCQM
#110 Preventative Care and Screening: Influenza ImmunizationMedicare Part B Claims, eCQM, MIPS CQM
#111 Pneumococcal Vaccination Status for Older AdultsMedicare Part B Claims, eCQM, MIPS CQM
#138 Melanoma: Coordination of CareMIPS CQM
#147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy Medicare Part B Claims, MIPS CQM
#283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and ManagementMIPS CQM
#324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk PatientsMIPS CQM
#391 Follow-Up After Hospitalization for Mental Illness (FUH)MIPS CQM
#402 Tobacco Use and Help with Quitting Among Adolescents MIPS CQM

There is a partial removal of 3 Quality measures (they will be retained for MVP use only):

Quality Measures Partially RemovedCollection Type
#112 Breast Cancer ScreeningMedicare Part B Claims, eCQM, MIPS CQM
#113 Colorectal Cancer ScreeningMedicare Part B Claims, eCQM, MIPS CQM
#128 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanMedicare Part B Claims, eCQM, MIPS CQM

They have also made substantive changes to 59 existing Quality measures:

  • `#226 – Tobacco Use: Screening and Cessation Intervention: This measure will be combined with measure #402 (Adolescent Tobacco Use Screening) to lower the denominator eligible age to 12 years old.

Promoting Interoperability

CMS has increased the minimum reporting period for the PI category from 90 continuous days to 180 continuous days. It is extremely vital that practices begin to implement the patient portal and stay on top of this category from the very beginning of the year. 

The small-practice automatic reweighting of the category will continue in 2024 except for the following clinician types:

  • – Physical Therapists
  • – Occupational Therapists
  • – Qualified Speech-Language Pathologists
  • – Clinical Psychologists
  • – Registered Dieticians or Nutrition Professionals 

Additionally, they have revised the exclusion for the Query of Prescription Drug Monitoring Program (PDMP) Measure definition. It will now read “does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs during the performance period”. Previously providers could claim the exclusion if they prescribed less than 100 controlled substances in the reporting period. Providers should verify they are registered with their state PMP and ensure they are checking the database before prescribing any controlled substances to their patients. 

In 2022 and 2023 the High Priority SAFER Guide was not required for attestation, a selection of “no” previously sufficed. In 2024, the SAFER Guide must be completed and saved to their documents similar to the Security Risk Assessment before they select “Yes” during attestation. 

ObjectiveMeasureMaximum PointsRequired/Optional
Electronic Prescribinge-Prescribing10 pointsRequired
Query of PDMP10 pointsRequired
Health Information Exchange Support Electronic Referral Loops by Sending Health Information15 pointsRequired (MIPS eligible clinician’s choice of one of the three reporting options)
Support Electronic Referral Loops by Receiving and Reconciling health Information 15 points
~OR~
Health Information Exchange Bi-Directional Exchange30 points
~OR~
Enabling Exchange under TEFCA30 points
Provider to Patient ExchangeProvide Patients Electronic Access to Their Health Information25 pointsRequired
Public Health and Clinical Data ExchangeReport the following two measures:Immunization Registry ReportingElectronic Case Reporting25 pointsRequired
Reporting one of the following measures:Public Health Registry ReportingClinical Data Registry ReportingSyndromic Surveillance Reporting5 points (bonus)Optional

Improvement Activities 

Addition of 5 new Improvement Activities:

  • – IA_PM_22: Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services Guidelines (submitted by the CDC)
  • – IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
  • – IA_PM_23: Use of Decision Support to Improve Adherence to Cervical Cancer Screening and Management
  • – IA_BMH_14: Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women
  • – IA_BMH_15: Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults

Removal of 3 Improvement Activities:

  • – IA_BMH_6: Implementation of colocation PCP and MH services
  • – IA_BMH_13: Obtain or Renew an Approved Waiver for Provision of Buprenorphine as Medication-Assisted Treatment [MAT] for Opioid Use Disorder
  • – IA_PSPA_29: Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging

Cost

The Simple pneumonia with Hospitalization measure has been removed for the 2024 reporting period. Moreover, CMS has added 5 new episode-based Cost measures for 2024 reporting:

  • – Depression (chronic condition)
  • – Emergency Medicine (care provided in an emergency department setting)
  • – Heart Failure (chronic condition)
  • – Low Back Pain (chronic condition)
  • – Psychoses and Related Conditions (acute inpatient medication condition)

MIPS Scoring

CMS did not finalize the proposal to raise the passing threshold from 75 to 82. This is good news for the 2024 reporting year. However, since they have already proposed an increase once, it is likely that they will include it in their 2025 proposal again. The chance that it will pass next year is higher, so it is imperative that practices have a quality system in place for working MIPS.   

The category weights will stay the same as previous reporting years

2024 Performance Period
QualityPromoting InteroperabilityImprovement ActivitiesCost
30%25%15%30%

MIPS Value Pathways (MVPs)

In addition to the existing MVPS, 5 will be added bringing the total available MVPs to 16 for the 2024 reporting year. CMS has also made modifications to the already existing MVPs, including combining the Promoting Wellness MVP with the Optimizing Chronic Disease Management MVP (now called the Value in Primary Care MVP).

Addition of 5 new MVPs:

  1. 1. Focusing on Women’s Health
  2. 2. Quality Care for the Treatment of Ear, Nose, and Throat Disorders
  3. 3. Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV
  4. 4. Quality Care in Mental Health and Substance Use Disorders
  5. 5. Rehabilitative Support for Musculoskeletal Care

Existing MVPs:

  1. 1. Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
  2. 2. Advancing Cancer Care
  3. 3. Advancing Care for Heart Disease
  4. 4. Advancing Rheumatology Patient Care
  5. 5. Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes
  6. 6. Improving Care for Lower Extremity Joint Repair
  7. 7. Optimal Care for Kidney Health
  8. 8. Optimal Care for Patients with Episodic Neurological Conditions
  9. 9. Patient Safet and Support of Positive Experiences with Anesthesia 
  10. 10. Value in Primary Care
  11. 11. Support Care for Neurodegenerative Conditions

Summary

The MIPS program has been getting increasingly difficult since its inception. As more updates and revisions happen to the program, it is critical for practices to stay up-to-date and make the adjustments to office workflows as needed. 

Please keep in mind that COVID hardships will no longer be available, and the Data Validation Audits have begun again. Accurate documentation is essential and attestation measure documents should be saved in case of future audits. 

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