Appendix M2 (See Table 25): 2022 MVP Candidates: Instructions and Template Crosswalk

MVP Development Standardized Template
CY 2021 Final versus CY 2022 Final
Burden impact: The changes to the MVP Development Standardized Template reflect
finalization of proposals, language updates, and additional text added from the CY 2021
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program to the CY 2022
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program. The result is an
estimated change of zero hours.
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Change #1:
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Reason for Change:
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CY 2021 Final Rule text:
Purpose
The Centers for Medicare & Medicaid Services (CMS) invites interested stakeholders to
develop and submit Merit-based Incentive Payment System (MIPS) Value Pathways (MVP)
candidates for evaluation and potential proposal in future rulemaking.
Please note that this solicitation is separate from the annual Call for Quality Measures, Call for
Improvement Activities, and Solicitation for Specialty Set recommendations.
CY 2022 Final Rule text:
Purpose
The Centers for Medicare & Medicaid Services (CMS) invites interested stakeholders to submit
Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) candidates for CMS
consideration and potential implementation through future rulemaking.
Please note that this solicitation is separate from the annual Call for Quality Measures, Call for
Improvement Activities, and Solicitation for Specialty Set Recommendations.
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CY 2021 Final Rule text:
About MVPs
With MVPs, CMS is aiming to reduce the burden and complexity associated with selecting from
a large inventory of quality measures, improvement activities, and cost measures.
As noted in the CY 2021 Physician Fee Schedule Final Rules, the MVP framework strives to
link measures and improvement activities that address a common clinical theme across the four
MIPS performance categories. More details regarding the intent of the MVP framework and the
latest 2021 Final Rule Fact Sheet can be accessed on the MVP website.
CY 2022 Final Rule text:
About MVPs
Through MVP implementation and reporting, CMS aims to improve patient outcomes, allow for
more meaningful reporting by specialists and other MIPS eligible clinicians, and reduce burden

and complexity associated with selecting from a large inventory of measures and activities
found under traditional MIPS.
MVPs should be focused on a given specialty, condition, and/or episode of care. CMS is
currently working to identify MVP development priorities and will publish a list of the identified
priorities for stakeholder reference in the near future.
Additionally, CMS is also interested in MVPs that measure the patient journey and care
experience longitudinally and would like to explore how MVPs could best measure the value of
and be utilized within a multi-disciplinary team-based care model.
CMS is also committed to closing the health equity gap in CMS Clinician Quality Programs as
discussed in the final rule. Therefore, CMS encourages the implementation of health equitybased improvement activities within MVPs.
As noted in the (CY) 2021 and CY 2022 Physician Fee Schedule Final Rules, the MVP
framework strives to link measures and improvement activities that address a common clinical
theme across the four MIPS performance categories. More details regarding the intent of the
MVP framework and the latest 2022 Final Rule Fact Sheet can be accessed on the MVP
website.
While MVP development is collaborative by nature, including having stakeholders collaborate
with one another and with patients, ultimately CMS will determine if the MVP is appropriate and
responsive to CMS and HHS priorities, and what the timing for implementation of the MVP
should be. If CMS determines that additional changes are needed for an MVP once it is
implemented, CMS may make take additional steps through notice and comment rulemaking to
make updates. All MVPs, whether they are new or existing MVPs with updates must undergo
notice and comment rulemaking and are subjected to the public comment period. CMS is
considered the lead and ultimately the owner of all MVPs that are established through the
rulemaking process.
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Reason for Change:
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CY 2021 Final Rule text:
Introduction
These instructions identify the information that should be completed and submitted, utilizing the
standardized template below, by stakeholders who wish to have their MVP candidate
considered by CMS for potential implementation beginning with the 2022 performance period
and future years.
MVP candidates should include measures and activities from across the Quality, Cost, and
Improvement Activities performance categories. Furthermore, the foundational layer of each
MVP candidate should also include the entire set of Promoting Interoperability measures and
the Hospital-Wide 30-Day All-Cause Unplanned Readmission (HWR) Measure.
Following the instructions provided, please complete and submit both Table 1 and Table 2 of
the template below for each intended MVP candidate.

•
•

Table 1 should include high-level descriptive information as outlined below.
Table 2 should include the specific quality measures, improvement activities, and cost
measures for the MVP candidate submission.
o Please note that CMS is not prescriptive regarding the number of measures and
activities that may be included in an MVP; therefore, when completing Table 2, the
number of rows included should reflect the number of measures/activities that are
necessary to describe the MVP candidate submission.

Furthermore, additional guidance and considerations for stakeholders to factor into decision
making with regards to the creation of MVP candidates, specifically when completing Table 2,
can be found in the appendix of this document.
CY 2022 Final Rule text:
Introduction
These instructions identify the information that should be submitted, utilizing the standardized
template below, by stakeholders who wish to have an MVP candidate considered by CMS for
potential implementation.
MVP candidates should include measures and activities from across the four performance
categories. The MVP candidate should include measures and activities across the quality, cost,
and improvement activities performance categories.
In the foundational layer, each MVP candidate includes the entire set of Promoting
Interoperability measures. Furthermore, the foundational layer includes two population health
measures: Q479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for
the Merit-based Incentive Payment Program (MIPS) Groups and Q484: Clinician and Clinician
Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic
Conditions. Note: In this template, submitters do not need to submit the Promoting
Interoperability measures and the population health measures because they are required
across all MVP candidates and cannot be changed.
Please complete and submit both Table 1 and Table 2a of the template below for each
intended MVP candidate. If both tables are not complete, CMS will be unable to consider
your submission.
•
•

Table 1 should include high-level descriptive information as outlined below.
Table 2a should include the specific quality measures, improvement activities, and cost
measures for the MVP candidate submission.
o Please note that CMS is not prescriptive regarding the number of measures and
activities that may be included in an MVP; therefore, when completing Table 2a, the
number of rows included should reflect the number of measures/activities that are
necessary to describe the MVP candidate submission.

Additional guidance and considerations for completing Table 2a can be found in the appendix of
this document.
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Quality Measures
The MIPS quality measures are mapped to 46 specialties and sub-specialties that provide
guidance for stakeholders developing MVP candidates based on specialties. Please view the
current MIPS quality measures list and their associated specialty sets in the 2020 MIPS Quality
Measures List on the Quality Payment Program Resource Library for more information.
Stakeholders may also submit MVP candidates based on a health condition (e.g. diabetes). In
instances where a quality measure closely related to the MVP candidate topic is not available, a
broadly applicable or cross-cutting measure that drives quality care in alignment with the MVP
topic would suffice. Examples of broadly applicable measures include:
• Measure Q47: Advance Care Plan
• Measure Q226: Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention.
Please review the 2020 Cross-Cutting Quality Measures list on the Quality Payment Program
Resource Library for more information.
The MIPS quality measures are also categorized by measure type, and are categorized as
such, in the MIPS quality measures list (see above link). CMS encourages the inclusion of
measures that fall into the Outcome, Patient Reported Outcome, and Patient
Engagement/Experience measure types to the extent feasible. As there may be limited
availability of Patient Reported Outcome Measures for all specialties, we encourage the use of
other measures that consider the patient in MVPs, such as patient surveys, patient satisfaction,
patient experience, or patient safety measures.
Qualified Clinical Data Registry (QDCR) measures may also be considered for inclusion in an
MVP so long as the measure has met all requirements, including being fully tested and
approved through the Self-Nomination process.
Measures that are currently outside the MIPS program need to follow the pre-rulemaking
process (e.g., Call for Measures and rulemaking) before they may be included in an MVP.
CY 2022 Final Rule text:
Quality Measures
The current inventory of MIPS quality measures and Quality Clinical Data Registry (QCDR)
measures include both cross-cutting and specialty/clinical topic specific quality measures.
Please view the current MIPS quality measures list and their associated specialty set and
measure properties in the 2021 MIPS Quality Measures List and 2021 Cross-Cutting Quality
Measures on the Quality Payment Program Resource Library for more information. Please view
the current QCDR measures list and measure properties in the 2021 Qualified Clinical Data
Registry (QCDR) Measure Specifications on the Quality Payment Program Resource Library for
more information.
• Measures that are currently outside the MIPS program need to follow the pre-rulemaking
process (i.e., Call for Measures and rulemaking) before they may be included in an
MVP.
• Qualified Clinical Data Registry (QDCR) measures may also be considered for inclusion
in an MVP as long as the measure has met all requirements, including being fully tested
at the clinician level and approved through the self-nomination process.
In addition, as described in the CY 2022 Physician Fee Schedule (PFS) final rule, when
developing MVP candidates, stakeholders must consider that:

•

•

MVPs must include at least one outcome measure that is relevant to the MVP topic and
each clinician specialty:
o An outcome measure may include the following measure types: Outcome,
Intermediate Outcome, and Patient Reported Outcome-based Performance
Measure.
 For example, a single specialty MVP is the Advancing Rheumatology
Patient Care MVP, as finalized in the 2022 PFS Final Rule. This MVP
was developed to include outcome measures for this single specialty.
o If an outcome measure is not available for a given clinician specialty, a High
Priority measure must be included and available for each clinician specialty
included.
 For example, an MVP that contains High Priority measures is the
Adopting Best Practices and Promoting Patient Safety within Emergency
Medicine MVP as finalized in the 2022 PFS Final Rule. This MVP
contains one outcome measure, but also includes quality measures that
are categorized as High Priority in the instance the outcome measure is
not applicable.
If there are outcomes-based administrative claims measures that are relevant for a given
clinical topic, it may be included within the quality component of an MVP.

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Improvement Activities
Improvement activities are broader in application and cover a wide range of clinician types and
health conditions. Improvement activities that best drive the quality of care addressed in the
MVP topic should be prioritized. Improvement activities should complement and/or supplement
the quality action of the measures in the MVP candidate submission, rather than duplicate it.
CY 2022 Final Rule text:
Improvement Activities
Improvement activities are broader in application and cover a wide range of clinician types and
health conditions. Improvement activities that best drive the quality of care addressed in the
MVP topic should be prioritized. Improvement activities should complement and/or supplement
the quality action of the measures in the MVP candidate submission, rather than duplicate it. In
addition, MVPs should seek to identify/incorporate opportunities to promote diversity, equity,
and inclusion by selecting health equity focused improvement activities; there are 23 health
equity focused improvement activities in the current inventory: 2021 Improvement Activities
Inventory.
New improvement activities may be submitted using the 2021 Call for Measures and Activities
process outlined on the Quality Payment Program Resource Library.
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CY 2021 Final Rule text:

Cost Measures
The current inventory of cost measures covers different types of care. Procedural episodebased cost measures apply to specialties (such as orthopedic surgeons) that perform
procedures of a defined purpose or type, and acute episode-based cost measures cover
clinicians (such as hospitalists) who provide care for specific acute inpatient conditions. There
are also two broader types of measures (population-based cost measures) that assess overall
costs of care for a patient’s admission to an inpatient hospital (MSPB Clinician measure) and for
primary care services that a patient receives (TPCC measure). In addition, the MIPS cost
measures are calculated for clinicians and clinician groups based on administrative claims data.
CY 2022 Final Rule text:
Cost Measures
The current inventory of cost measures covers different types of care. Procedural episodebased cost measures apply to specialties (such as orthopedic surgeons) that perform
procedures of a defined purpose or type, acute episode-based cost measures cover clinicians
(such as hospitalists) who provide care for specific acute inpatient conditions , and chronic
condition episode-based cost measures account for the ongoing management of a disease or
condition. There are also two broader types of measures (population-based cost measures)
that assess overall costs of care for a patient’s admission to an inpatient hospital (Medicare
Spending Per Beneficiary (MSPB) Clinician measure) and for primary care services that a
patient receives (Total Per Capita Cost (TPCC) measure). In addition, the MIPS cost measures
are calculated for clinicians and clinician groups based on administrative claims data. Cost
measure information can be located on the MACRA Feedback Page.
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CY 2021 Final Rule text:
Submission and Review Process
On an annual basis, CMS intends to host a public-facing MVP development webinar to remind
stakeholders of MVP development criteria as well as the timeline and process to submit a
candidate MVP. While CMS believes that engagement with stakeholders regarding MVP
candidates may occur on a rolling basis throughout the year, at CMS’s discretion the agency
will determine if an MVP is ready for inclusion in the upcoming performance period.
As MVP candidates are received, they will be reviewed, vetted, and evaluated by CMS and our
contractors. CMS intends on utilizing the MVP development criteria (see Appendix) to
determine if the candidate MVP is feasible. In addition to the MVP development criteria, CMS
will also vet the quality and cost measures from a technical perspective to validate that the
coding in the quality measures and cost measure(s) include the clinician type being measured
and whether all potential specialty-specific quality measures or cost measures were considered,
with the most appropriate included.
We may reach out to stakeholders on an as-needed basis, should questions arise during the
review process. To continue collaborative efforts, once an internal evaluation is completed,
CMS will reach out to select stakeholders whose candidate MVP may be feasible for the
upcoming performance period to schedule a meeting to have an iterative dialog regarding our
feedback and next steps that may include recommended modifications to the MVP candidate.
Please note that submitting an MVP candidate does not guarantee it will be accepted for the
rulemaking process. To ensure a fair and transparent rulemaking process, CMS will not be able

to directly communicate (to those who submit MVP candidates) whether an MVP candidate has
been approved, disapproved, or is being considered for a future year, prior to the publication of
the proposed rule.
Completed MVP candidate templates (inclusive of Table 1 and Table 2) should be
submitted to PIMMSQualityMeasuresSupport@gdit.com for CMS evaluation.
CY 2022 Final Rule text:
Submission and Review Process
On an annual basis, CMS intends to host a public-facing MVP development webinar to remind
stakeholders of MVP development criteria as well as the timeline and process to submit a
candidate MVP. While CMS believes that engagement with stakeholders regarding MVP
candidates may occur on a rolling basis throughout the year, at CMS’s discretion the agency
will determine if an MVP is ready for inclusion in the upcoming performance period. Candidate
MVP submissions must be submitted no later than February 1, 2022, to be considered for
potential inclusion in the upcoming notice of proposed rulemaking and, if finalized, subsequent
implementation beginning with the CY 2023 performance period/2025 MIPS payment year.
As MVP candidates are received, they will be reviewed, vetted, and evaluated by CMS and its
contractors. CMS will utilize the MVP development criteria (see Appendix below) to determine if
the candidate MVP is feasible. In addition to the MVP development criteria, CMS will also vet
the quality and cost measures from a technical perspective to validate that the coding in the
quality measures and cost measures include the clinician type being measured and whether all
potential specialty-specific quality measures or cost measures were considered, with the most
appropriate included.
CMS may reach out to stakeholders on an as-needed basis should questions arise during the
review process. Please note that submitting an MVP candidate does not guarantee it will be
considered or accepted for the rulemaking process. To ensure a fair and transparent
rulemaking process, CMS will not be able to directly communicate (to those who submit MVP
candidates) whether an MVP candidate has been approved, disapproved, or is being
considered for a future year, prior to the publication of the proposed rule.
Completed MVP candidate templates (inclusive of Table 1 and Table 2a) should be
submitted to PIMMSMVPSupport@gdit.com for CMS evaluation.
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CY 2021 Final Rule text:
Table 1: Instructions and Template
Please describe high-level information to address the following general topics: MVP Name,
Primary/Alternative Points of Contact, Intent of Measurement, Measure and Activity Linkages
with the MVP, Appropriateness, Comprehensibility, and Incorporation of the Patient Voice. A
checklist of items are provided in Table 1 to provide further guidance.
CY 2022 Final Rule text:
Table 1: Instructions and Template
Please describe high-level information to address the following general topics: MVP Name,
Primary/Alternative Points of Contact, Intent of Measurement, Measure and Activity Linkages

with the MVP, Appropriateness, Comprehensibility, and Incorporation of the Patient Voice. A
checklist of items is provided in Table 1 to provide further guidance.
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CY 2021 Final Rule text:
TABLE 1: MVP DESCRIPTIVE INFORMATION
Incorporation of the Patient Voice
• How are patients involved in the MVP development process?
CY 2022 Final Rule text:
TABLE 1: MVP DESCRIPTIVE INFORMATION
Incorporation of the Patient Voice
• How were patients involved in the MVP development process?
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CY 2021 Final Rule text:
Table 2: Instructions and Template
Please use the Table 2 template format below to identify the quality measures, improvement
activities, and cost measures for your MVP candidate. Specifically, at a minimum, Table 2
should include measure/activity IDs, measure/activity titles, measure collection types, and
rationales for inclusion.
Please refer to the Appendix for further guidance regarding measure and activity selection.
As a reminder, CMS is not prescriptive regarding the number of measures and activities that
may be included in an MVP; therefore, when completing Table 2, the number of rows included
should reflect the number of measures/activities that are necessary to describe the MVP
candidate submission. Please add or remove rows as needed.
The foundational layer of measures are included below (Table 2b and 2c) and are pre-filled for
each MVP candidate submission.
CY 2022 Final Rule text:
Table 2a: Instructions and Template
Please use the Table 2a template format below to identify the quality measures, improvement
activities, and cost measures for your MVP candidate. Specifically, at a minimum, Table 2a
should include measure/activity IDs, measure/activity titles, measure collection types, and
rationales for inclusion.
Generally, an MVP should include a sufficient number of quality/cost measures and
improvement activities to allow MVP Participants to select measures and activities to meet the
reporting requirements. To the extent feasible, MVPs should include a maximum of 10 quality
measures and 10 improvement activities to offer MVP Participants some choice without being
overwhelming. However, CMS understands that the total number of quality measures and

activities available in an MVP would depend on the MVP structure. For example, the Optimizing
Chronic Disease Management MVP includes 9 quality measures and 12 improvement activities.
Chronic disease can broadly encompass several conditions; therefore, CMS has selected
measures and improvement activities that are closely aligned to the topic and offer clinicians
some choice. Additionally, each MVP must include at least one cost measure relevant and
applicable to the MVP topic. The number of cost measures in a given MVP may vary depending
on the clinical topic of the MVP.
As CMS is not prescriptive regarding the number of measures and activities that may be
included in an MVP when completing Table 2a, the number of rows included should reflect the
number of measures/activities that are necessary to describe the MVP candidate submission.
The foundational layer of measures is included below (Tables 2b and 2c) and is pre-filled for
each MVP candidate submission and cannot be changed.
Please refer to the Appendix below for further guidance regarding measure and activity
selection.
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Reason for Change:
Update to Table title. Update to measure name for Hospital-Wide, 30-Day, All-Cause Unplanned
Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups
measure and removal of descriptive text. Addition of Clinician and Clinician Group Riskstandardized Hospital Admission Rates for Patients with Multiple Chronic Conditions measure
with corresponding table elements.

CY 2021 Final Rule text:

TABLE 2: FOUNDATIONAL LAYER – POPULATION HEALTH MEASURE
QUALITY
MEASURE TITLE
COLLECTION MEAUSRE
NQS
#
AND
TYPE
TYPE/
DOMAIN
DESCRIPTION
HIGH
PRIORITY
Hospital-Wide, 30479
Administrative
Outcome
Communicati
Day, All-Cause
Claims
on and Care
Unplanned
Coordination
Readmission (HWR)
Rate for the MeritBased Incentive
Payment Program
(MIPS) Eligible
Clinician Groups
This measure is a
re-specified version
of the measure,
“Risk-adjusted
readmission rate
(RARR) of
unplanned
readmission within
30 days of hospital
discharge for any
condition” (NQF
1789), which was
developed for
patients 65 years
and older using
Medicare claims.
This re-specified
measure attributes
outcomes to MIPS
participating clinician
groups and
assesses each
group’s readmission
rate. The measure
comprises a single
summary score,
derived from the
results of five
models, one for
each of the following
specialty cohorts
(groups of discharge
condition categories
or procedure
categories):
medicine, surgery/
gynecology, cardiorespiratory,
cardiovascular, and
neurology.

HEALTH CARE
PRIORITY

MEASURE
STEWARD

Promote
Effective
Communication
& Coordination
of Care

Yale
University

CY 2022 Final Rule text:

TABLE 2: FOUNDATIONAL LAYER – POPULATION HEALTH MEASURE
QUALITY MEASURE
COLLECTION MEAUSRE NQS DOMAIN
#
TITLE AND
TYPE
TYPE /
DESCRIPTION
HIGH
PRIORITY
Hospital-Wide,
479
Administrative
Outcome
Communication
30-Day, AllClaims
and Care
Cause
Coordination
Unplanned
Readmission
(HWR) Rate for
the Merit-Based
Incentive
Payment
Program (MIPS)
Groups
484

Clinician and
Clinician Group
Riskstandardized
Hospital
Admission Rates
for Patients with
Multiple Chronic
Conditions

Administrative
Claims

Outcome

Effective
Clinical Care

HEALTH
CARE
PRIORITY

MEASURE
STEWARD

Promote
Effective
Communication
& Coordination
of Care

CMS

Promote
Effective
Prevention and
Treatment of
Chronic
Disease

CMS

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Safety Assurance Factors for EHR Resilience Guide (SAFER Guide), and updated language for
alignment with current year.
CY 2021 Final Rule text:

TABLE 2: FOUNDATIONAL LAYER – PROMOTING INTEROPERABILITY MEASURES
OBJECTIVE MEASURE ID, TITLE, AND DESCRIPTION
EXCLUSION
REQUIRED
AVAILABLE
FOR PI
Protect
PI_PPHI_1: Security Risk Analysis:
No
Yes
Patient
Conduct or review a security risk analysis in
Health
accordance with the requirements in 45 CFR
Information
164.308(a)(1), including addressing the
security (to include encryption) of ePHI data
created or maintained by certified electronic
health record technology (CEHRT) in
accordance with requirements in 45 CFR
164.312(a)(2)(iv) and 45 CFR 164.306(d)(3),
implement security updates as necessary,
and correct identified security deficiencies as
part of the MIPS eligible clinician’s risk
management process.
ePI_EP_1: e-Prescribing:
Yes
Yes
Prescribing
At least one permissible prescription written
by the MIPS eligible clinician is queried for a
drug formulary and transmitted electronically

ADDITIONAL
INFORMATION
Annual
requirement for PI
submission but
not scored.

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

ePrescribing

PI_EP_2: Query of Prescription Drug
Monitoring Program (PDMP):

Provider to
Patient
Exchange

For at least one Schedule II opioid
electronically prescribed using CEHRT
during the performance period, the MIPS
eligible clinician uses data from CEHRT to
conduct a query of a PDMP for prescription
drug history, except where prohibited and in
accordance with applicable law.
PI_PEA_1: Provide Patients Electronic
Access to Their Health Information:
For at least one unique patient seen by the
MIPS eligible clinician: (1) The patient (or the
patient-authorized representative) is
provided timely access to view online,
download, and transmit his or her health
information; and (2) The MIPS eligible
clinician ensures the patient's health
information is available for the patient (or
patient-authorized representative) to access
using any application of their choice that is
configured to meet the technical
specifications of the Application
Programming Interface (API) in the MIPS
eligible clinician's certified electronic health
record technology (CEHRT).

EXCLUSION
AVAILABLE
No

REQUIRED
FOR PI
No

No

Yes

ADDITIONAL
INFORMATION
Bonus PI
measure at this
time

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

Health
Information
Exchange

PI_HIE_1: Support Electronic Referral
Loops by Sending Health Information:
For at least one transition of care or referral,
the MIPS eligible clinician that transitions or
refers their patient to another setting of care
or health care provider — (1) creates a
summary of care record using certified
electronic health record technology
(CEHRT); and (2) electronically exchanges
the summary of care record.

EXCLUSION
AVAILABLE
Yes

REQUIRED
FOR PI
Yes

ADDITIONAL
INFORMATION
A new optional
alternative Health
Information
Exchange (HIE)
bi-directional
exchange
measure may be
reported as an
alternative
reporting option to
the two existing
measures under
the HIE objective
that would allow
an eligible
clinician to attest
to participation in
bi-directional
exchange through
an HIE using
CEHRT
functionality.
This new
measure,
PI_HIE_5:
Engagement in
Bi-directional
Exchange
through Health
Information
Exchange (HIE),
would be reported
in place of
PI_HIE_1 and
PI_HIE_4.

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

Health
Information
Exchange

PI_HIE_4: Support Electronic Referral
Loops by Receiving and Reconciling
Health Information:

EXCLUSION
AVAILABLE
Yes

REQUIRED
FOR PI
Yes

For at least one electronic summary of care
record received for patient encounters during
the performance period for which a MIPS
eligible clinician was the receiving party of a
transition of care or referral, or for patient
encounters during the performance period in
which the MIPS eligible clinician has never
before encountered the patient, the MIPS
eligible clinician conducts clinical information
reconciliation for medication, medication
allergy, and current problem list.

Public
Health and
Clinical Data
Exchange

Public
Health and
Clinical Data
Exchange

PI_PHCDRR_1: Immunization Registry
Reporting:
The MIPS eligible clinician is in active
engagement with a public health agency to
submit immunization data and receive
immunization forecasts and histories from
the public health immunization registry
/immunization information system (IIS).
PI_PHCDRR_2: Syndromic Surveillance
Reporting:
The MIPS eligible clinician is in active
engagement with a public health agency to
submit syndromic surveillance data from an
urgent care setting.

Yes

Yes

Yes

Yes

ADDITIONAL
INFORMATION
A new optional
alternative Health
Information
Exchange (HIE)
bi-directional
exchange
measure may be
reported as an
alternative
reporting option to
the two existing
measures under
the HIE objective
that would allow
an eligible
clinician to attest
to participation in
bi-directional
exchange through
an HIE using
CEHRT
functionality.
This new
measure,
PI_HIE_5:
Engagement in
Bi-directional
Exchange
through Health
Information
Exchange (HIE)
would be reported
in place of
PI_HIE_1 and
PI_HIE_4.
Only 2 of 5
measures in the
objective must be
submitted or 1
measure if
multiple registry
engagement
Only 2 of 5
measures in the
objective must be
submitted or 1
measure if
multiple registry
engagement

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

Public
Health and
Clinical Data
Exchange

PI_PHCDRR_3: Electronic Case
Reporting:

Public
Health and
Clinical Data
Exchange

PI_PHCDRR_4: Public Health Registry
Reporting:

Public
Health and
Clinical Data
Exchange

PI_PHCDRR_5: Clinical Data Registry
Reporting:

EXCLUSION
AVAILABLE
Yes

REQUIRED
FOR PI
Yes

Yes

Yes

Yes

Yes

The MIPS eligible clinician is in active
engagement with a public health agency to
electronically submit case reporting of
reportable conditions.

The MIPS eligible clinician is in active
engagement with a public health agency to
submit data to public health registries.

The MIPS eligible clinician is in active
engagement to submit data to a clinical data
registry.

ADDITIONAL
INFORMATION
Only 2 of 5
measures in the
objective must be
submitted or 1
measure if
multiple registry
engagement
Only 2 of 5
measures in the
objective must be
submitted or 1
measure if
multiple registry
engagement
Only 2 of 5
measures in the
objective must be
submitted or 1
measure if
multiple registry
engagement

CY 2022 Final Rule text:

TABLE 2: FOUNDATIONAL LAYER – PROMOTING INTEROPERABILITY MEASURES
OBJECTIVE MEASURE ID, TITLE, AND
EXCLUSION REQUIRED FOR
DESCRIPTION
AVAILABLE PROMOTING
INTEROPERABILITY
Protect
PI_PPHI_1: Security Risk
No
Yes
Patient
Analysis:
Health
Conduct or review a security risk
Information
analysis in accordance with the
requirements in 45 CFR
164.308(a)(1), including addressing
the security (to include encryption) of
ePHI data created or maintained by
certified electronic health record
technology (CEHRT) in accordance
with requirements in 45 CFR
164.312(a)(2)(iv) and 45 CFR
164.306(d)(3), implement security
updates as necessary, and correct
identified security deficiencies as
part of the MIPS eligible clinician’s
risk management process.
Protect
PI_PPHI_2: Safety Assurance
No
Yes
Patient
Factors for EHR Resilience Guide
Health
(SAFER Guide):
Information
Conduct an annual self-assessment
using the High Priority Practices
Guide at any point during the
calendar year in which the
performance period occurs.

ADDITIONAL
INFORMATION
Annual
requirement for
Promoting
Interoperability
submission but
not scored.

Annual
requirement for
Promoting
Interoperability
submission but
not scored.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

ePrescribing

PI_EP_1: e-Prescribing:

ePrescribing

At least one permissible prescription
written by the MIPS eligible clinician
is queried for a drug formulary and
transmitted electronically
PI_EP_2: Query of Prescription
Drug Monitoring Program (PDMP):

Provider to
Patient
Exchange

For at least one Schedule II opioid
electronically prescribed using
CEHRT during the performance
period, the MIPS eligible clinician
uses data from CEHRT to conduct a
query of a PDMP for prescription
drug history, except where
prohibited and in accordance with
applicable law.
PI_PEA_1: Provide Patients
Electronic Access to Their Health
Information:
For at least one unique patient seen
by the MIPS eligible clinician: (1)
The patient (or the patientauthorized representative) is
provided timely access to view
online, download, and transmit his or
her health information; and (2) The
MIPS eligible clinician ensures the
patient's health information is
available for the patient (or patientauthorized representative) to access
using any application of their choice
that is configured to meet the
technical specifications of the
Application Programming Interface
(API) in the MIPS eligible clinician's
certified electronic health record
technology (CEHRT).

ADDITIONAL
INFORMATION

Yes

REQUIRED FOR
PROMOTING
INTEROPERABILITY
Yes

No

No

Bonus Promoting
Interoperability
measure at this
time

No

Yes

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

Health
Information
Exchange

PI_HIE_1: Support Electronic
Referral Loops by Sending Health
Information:

Yes

REQUIRED FOR
PROMOTING
INTEROPERABILITY
Yes

Yes

Yes

No

Yes

For at least one transition of care or
referral, the MIPS eligible clinician
that transitions or refers their patient
to another setting of care or health
care provider — (1) creates a
summary of care record using
certified electronic health record
technology (CEHRT); and (2)
electronically exchanges the
summary of care record.

Health
Information
Exchange

PI_HIE_4: Support Electronic
Referral Loops by Receiving and
Reconciling Health Information:
For at least one electronic summary
of care record received for patient
encounters during the performance
period for which a MIPS eligible
clinician was the receiving party of a
transition of care or referral, or for
patient encounters during the
performance period in which the
MIPS eligible clinician has never
before encountered the patient, the
MIPS eligible clinician conducts
clinical information reconciliation for
medication, medication allergy, and
current problem list.

Health
Information
Exchange

PI_HIE_5: Health Information
Exchange (HIE) Bi-Directional
Exchange:
The MIPS eligible clinician or group
must attest that they engage in
bidirectional exchange with an HIE
to support the transitions of care

ADDITIONAL
INFORMATION
The optional
PI_HIE_5: Health
Information
Exchange (HIE)
Bi-Directional
Exchange
measure may be
reported as an
alternative
reporting option
to PI_HIE_1 and
PI_HIE_4 which
would allow an
eligible clinician
to attest to
participation in
bi-directional
exchange
through an HIE
using CEHRT
functionality.
The optional
PI_HIE_5: Health
Information
Exchange (HIE)
Bi-Directional
Exchange
measure may be
reported as an
alternative
reporting option
to PI_HIE_1 and
PI_HIE_4 which
would allow an
eligible clinician
to attest to
participation in
bi-directional
exchange
through an HIE
using CEHRT
functionality.
This measure is
an optional
alternative
Health
Information
Exchange (HIE)
bi-directional
exchange
measure and
may be reported
as an alternative
reporting option
in place of
PI_HIE_1 and
PI_HIE_4.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

Public
Health and
Clinical Data
Exchange

PI_PHCDRR_1: Immunization
Registry Reporting:

Public
Health and
Clinical Data
Exchange

Public
Health and
Clinical Data
Exchange

Public
Health and
Clinical Data
Exchange

Public
Health and
Clinical Data
Exchange

The MIPS eligible clinician is in
active engagement with a public
health agency to submit
immunization data and receive
immunization forecasts and histories
from the public health immunization
registry /immunization information
system (IIS).
PI_PHCDRR_2: Syndromic
Surveillance Reporting:
The MIPS eligible clinician is in
active engagement with a public
health agency to submit syndromic
surveillance data from an urgent
care setting.
PI_PHCDRR_3: Electronic Case
Reporting:
The MIPS eligible clinician is in
active engagement with a public
health agency to electronically
submit case reporting of reportable
conditions.
PI_PHCDRR_4: Public Health
Registry Reporting:
The MIPS eligible clinician is in
active engagement with a public
health agency to submit data to
public health registries.
PI_PHCDRR_5: Clinical Data
Registry Reporting:
The MIPS eligible clinician is in
active engagement to submit data to
a clinical data registry.

ADDITIONAL
INFORMATION

Yes

REQUIRED FOR
PROMOTING
INTEROPERABILITY
Yes

No

No

Bonus Promoting
Interoperability
measure at this
time

Yes

Yes

No

No

Bonus Promoting
Interoperability
measure at this
time

No

No

Bonus Promoting
Interoperability
measure at this
time

*****
Change #13:
Location: Page 13
Reason for Change:
Language updates
CY 2021 Final Rule text:
Appendix: Quality Measures:
•
•
•

Do the quality measures included in the MVP meet the existing quality measure inclusion
criteria? (For example, does the measure demonstrate a performance gap?)
Have the quality measure denominators been evaluated to ensure the applicability across
the measures and activities within the MVP?
Have the quality measure numerators been assessed to ensure the measure is applicable
to the MVP topic?

•

To the extent feasible, does the MVP include outcome measures or high-priority measures
in instances where outcome measures are not available or applicable?
-

•
•
•
•
•

CMS prefers use of patient experience/survey measures when available. CMS
encourages stakeholders to utilize our established pre-rulemaking processes, such as
the Call for Measures, described in the CY 2020 PFS final rule (84 FR 62953 through
62955) to develop outcome measures relevant to their specialty if outcome measures
currently do not exist and for eventual inclusion into an MVP.

To the extent feasible, does the MVP avoid including quality measures that are topped
out?
What collection types are the measures available through?
What role does each quality measure play in driving quality care and improving value
within the MVP?
How do the selected quality measures relate to other measures and activities in the other
performance categories?
To the extent feasible, specialty and sub-specialty specific quality measures are
incorporated into the MVP. Broadly applicable (cross-cutting) quality measures may be
incorporated if relevant to the clinicians being measured.

CY 2022 Final Rule text:
Appendix: Quality Measures:
•
•
•
•

Do the quality measures included in the MVP meet the existing quality measure inclusion
criteria? (For example, does the measure demonstrate a performance gap?)
Have the quality measure denominators been evaluated to ensure the applicability across
the measures and activities within the MVP?
Have the quality measure numerators been assessed to ensure the measure is applicable
to the MVP topic?
Does the MVP include outcome measures or high-priority measures in instances where
outcome measures are not available or applicable?
-

•
•
•
•
•

CMS prefers use of patient experience/survey measures when available. CMS
encourages stakeholders to utilize our established pre-rulemaking processes, such as
the Call for Measures, described in the CY 2020 PFS Final Rule (84 FR 62953 through
62955) to develop outcome measures relevant to their specialty if outcome measures
currently do not exist and for eventual inclusion into an MVP.

To the extent feasible, does the MVP avoid including quality measures that are topped
out?
What collection types are the measures available through?
What role does each quality measure play in driving quality care, improving value, and
addressing the health equity gap within the MVP?
How do the selected quality measures relate to other measures and activities in the other
performance categories?
To the extent feasible, specialty and sub-specialty specific quality measures are
incorporated into the MVP. Broadly applicable (cross-cutting) quality measures may be
incorporated if relevant to the clinicians being measured.