CROSSWALK Appendix J: 2025 MVP Candidates: Instructions and Template

MVP Development Standardized Template
CY 2024 Final versus CY 2025 Final
Burden impact: The changes to the MVP Development Standardized Template reflect
finalization of proposals, language updates, and additional text added from the CY 2024
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program to the CY 2025
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program. The result is an
estimated change of zero hours.
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CY 2024 Final Rule text:
Purpose
The Centers for Medicare & Medicaid Services (CMS) invites the general public to submit Meritbased 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.
CY 2025 Final Rule text:
Purpose
The Centers for Medicare & Medicaid Services (CMS) invites the interested parties to submit
Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) candidates for CMS’
consideration and potential implementation through future rulemaking.
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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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 provide a pathway for clinicians to report on an applicable clinical topic based on their
specialty, their medical condition focus, or the setting in which they provide patient care. CMS
has identified a list of specialties/clinical topics that are considered priorities for MVP
development and encourages the general public to submit MVPs that incorporate the identified

specialties. Please review the MVP Needs and Priorities document found within the MVPs
Development Resources ZIP file for additional information, available on the MVP Candidate
Development & Submission webpage.
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 can be found on the MVP Candidate Development &
Submission webpage.
While stakeholder feedback in MVP development is appreciated, ultimately CMS will determine
if a given MVP candidate will move forward through rulemaking. CMS owns all MVPs that are
established through notice and comment rulemaking. CMS will determine if the MVP is
appropriate and responsive to the needs and priorities of the Agency, Department, and
Administration. In addition to determining if an MVP candidate aligns with programmatic needs,
CMS will also determine when an MVP candidate is ready for proposal through rulemaking for
future implementation.
In the CY 2023 PFS Final Rule, we finalized the modification of the MVP development process
to include a 30-day feedback period for the general public to submit feedback on candidate
MVPs prior to potentially including an MVP in a notice of proposed rulemaking.
All MVPs, whether they are new or existing MVPs with updates, must undergo notice and
comment rulemaking and are subject to the public comment period. If CMS determines that
additional changes are needed for an MVP once it is implemented, CMS may take additional
steps through notice and comment rulemaking to make updates.
CY 2025 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 provide a pathway for clinicians to report on an applicable clinical topic based on their
specialty, their medical condition focus, or the setting in which they provide patient care. CMS
has identified priority specialties and clinical topics for MVP development. Interested parties are
encouraged to submit MVPs that address these priority areas. The 2025 MVP “Needs and
Priorities” document provides additional information and will be available in the QPP website,
MVP Candidate Development & Submission webpage, MVPs Development Resources ZIP file.
The MVP framework strives to link measures and improvement activities that address a
common clinical theme across the 4 MIPS performance categories. More details regarding the
intent of the MVP framework can be found on the MVP Candidate Development & Submission
webpage.
While stakeholder feedback in MVP development is appreciated, ultimately CMS will determine
if a given MVP candidate will move forward through rulemaking. CMS owns all MVPs that are
established through notice and comment rulemaking. CMS will determine if the MVP is
appropriate and responsive to the needs and priorities of the Agency, Department, and
Administration. In addition to determining if an MVP candidate aligns with programmatic needs,

CMS will also determine when an MVP candidate is ready for proposal through rulemaking for
future implementation.
In the Calendar Year (CY) 2023 Physician Fee Schedule (PFS) Final Rule, we finalized the
modification of the MVP development process to include a 30-day feedback period for
interested parties to submit feedback on candidate MVPs prior to potentially including an MVP
in a notice of proposed rulemaking. At the discretion of CMS and when possible, we will extend
the 30-day feedback period up to 45-days in order to give interested parties additional time to
provide feedback.
All MVPs, whether they are new or existing MVPs with updates, must undergo notice and
comment rulemaking and are subject to the public comment period. If CMS determines that
additional changes are needed for an MVP once it’s implemented, CMS may take additional
steps through notice and comment rulemaking to make updates.
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Introduction
These instructions identify the information the general public should submit, using the
standardized template below, if they wish to have an MVP candidate considered by CMS for
potential implementation.
MVP candidates include measures and activities from across the four performance categories.
MVP candidate submissions should include measures and activities across the quality, cost,
and improvement activities performance categories.
Each MVP includes what is referred to as the foundational layer, which includes the Promoting
Interoperability measure/objective set and 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.
Promoting Interoperability performance category measures don’t need to be included in MVP
candidate submissions. The foundational layer measures are prefilled in the template because
they are required across all MVP candidates and can’t be changed. The Promoting
Interoperability performance category measure specifications are available on the Promoting
Interoperability Performance Category webpage.
Please complete and submit Table 1 and Table 2A of the template below for each intended
MVP candidate. Both tables must be completed for CMS 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.

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Please note that CMS isn’t 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.
CY 2025 Final Rule text:
Introduction
Use the standardized template below to submit an MVP candidate for consideration. MVP
candidate submissions should include measures and activities across the quality, cost, and
improvement activities performance categories. In addition to these core performance
categories, each MVP candidate includes what is referred to as the foundational layer, which
includes the Promoting Interoperability measure/objective set and 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.
The foundational layer measures are prefilled in the template (Tables 2B and 2C) because they
are required across all MVP candidates and can’t be changed. The Promoting Interoperability
performance category measure specifications are available on the Promoting Interoperability
Performance Category webpage.
Complete and submit Table 1 and Table 2A of the template below for each intended MVP
candidate. Both tables must be completed for CMS 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 CMS isn’t prescriptive regarding the number of measures and activities that may be
included in an MVP as long as there are a sufficient number of measures and activities
to meet the reporting requirements; 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.
o IA_PCMH is included in all MVPs because MIPS eligible clinicians in a patientcentered medical home or comparable specialty practice may attest to it and receive
an improvement activity score of 100 percent per statute (Code of Federal Regulations
§ 414.1380(b)(3)(ii)).
o IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways is included in
all MVPs as it was developed specifically for MVP reporting.
Additional guidance and considerations for completing Table 2A can be found in the Appendix.
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CY 2024 Final Rule text:

MVP Candidate Content and Review Process

CMS encourages MVP submissions to include quality/cost measures and improvement
activities that are currently available in MIPS. To view all MIPS measures and improvement
activities, please visit the Quality Payment Program Resource Library or review the most recent
Measures Under Consideration (MUC) list. Measures and/or improvement activities not
currently in the MIPS inventory will be required to follow the existing pre-rulemaking processes
to be considered for inclusion within an MVP.
CY 2025 Final Rule text:
MVP Candidate Content and Review Process
CMS encourages MVP submissions to include quality/cost measures and improvement
activities that are currently available in MIPS. To view all MIPS measures and improvement
activities, please visit the Quality Payment Program (QPP) Resource Library or review the most
recent Measures Under Consideration (MUC) list. Measures and/or improvement activities not
currently in the MIPS inventory will be required to follow the existing pre-rulemaking processes
to be considered for inclusion within an MVP.
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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. The
following 2024 resources will be available on the QPP Resource Library:
• 2024 MIPS Quality Measures List (XLSX)
• 2024 Cross-Cutting Quality Measures (PDF)
• 2024 QCDR Measure Specifications (XLSX)
QDCR measures may also be considered for inclusion in an MVP if 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, the general public should 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. This MVP was developed to include an outcome
measure related to care provided by this single specialty.

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If an outcome measure isn’t 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. 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.
Outcome-based administrative claims measures may be included to support the
quality performance category of an MVP candidate.

CY 2025 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. The
following 2025 resources will be available on the QPP Resource Library:
• 2025 MIPS Quality Measures List (XLSX)
• 2025 Cross-Cutting Quality Measures (PDF)
• 2025 QCDR Measure Specifications (XLSX)
QDCR measures may also be considered for inclusion in an MVP if 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 PFS final rule, when developing MVP candidates, the
interested parties should 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.
 An example of a single specialty MVP is the Patient Safety and Support
of Positive Experiences with Anesthesia MVP. This MVP was developed
to include an outcome measure related to care provided by this specialty.
o If an outcome measure isn’t available for a given clinician specialty, a high
priority measure must be included and available for each clinician specialty
included.
 An example of an MVP that contains high priority measures is the
Advancing Cancer Care MVP. 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.
o Outcome-based administrative claims measures may be included to support the
quality performance category of an MVP candidate.
 An example of an MVP containing an outcome-based administrative
claims measure for use in the quality performance category is the
Improving Care for Lower Extremity Joint Repair 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.
In addition, MVPs should seek to identify/incorporate opportunities to promote diversity, equity,
and inclusion by selecting health equity focused improvement activities; there are 36 health
equity focused improvement activities in the current inventory. The 2024 Improvement Activity
Inventory will be available on the QPP Resource Library.
New improvement activities may be submitted using the 2024 Call for Measures and Activities
process, which will outlined on the QPP Resource Library.
CY 2025 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 36 health
equity focused improvement activities in the current inventory. The 2025 Improvement Activity
Inventory will be available on the QPP Resource Library.
New improvement activities may be submitted using the 2025 Call for Measures and Activities
process, which will outlined on the QPP Resource Library.
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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 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. The following cost
measure information will be available on the QPP Website:
• MIPS 2024 Summary of Cost Measures (PDF): Provides an overview of the cost
measures, their development, and estimated cost and clinician coverage metrics for the
measures currently in use.
• Measure Information Form (ZIP): Describes the methodology used to construct each
measure.
• Measure Codes List (ZIP): Contains service codes and clinical logic used in the
methodology, including episode triggers, exclusion categories, episode subgroups,
assigned items and services, and risk adjustors.
New cost measures may be submitted for consideration for use in the MIPS program using the
2024 Call for Measures and Activities process, which will be outlined on the QPP Resource
Library.
CY 2025 Final Rule text:
Cost Measures
The current inventory of cost measures covers different types of care. Episode-based cost
measures assess specific clinically related costs during a defined period, or “episode of care.”
These measures can apply to clinicians and clinicians groups who perform procedures (e.g.,
knee arthroplasty), treat patients during acute inpatient hospitalizations (e.g. stays for lower
gastrointestinal hemorrhage), provide ongoing chronic condition management (e.g., ongoing
diabetes care), or practice in certain settings (e.g., an emergency department).
There are also two broader measures (population-based cost measures) that assess overall
costs of care. The Medicare Spending Per Beneficiary (MSPB) Clinician measure assesses
costs of care for a patient's inpatient hospital stay during the period 3 days prior to a hospital
stay through 30 days after discharge. The Total Per Capita Cost (TPCC) measure assesses
the overall cost of care delivered to a patient with a focus on the primary care they receive from
their providers.
The following cost measure information will be available on the QPP website:
• MIPS 2025 Summary of Cost Measures (PDF): Provides an overview of the cost
measures, their development, and estimated cost and clinician coverage metrics for the
measures currently in use.

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•

Measure Information Form (ZIP): Describes the methodology used to construct each
measure.
Measure Codes List (ZIP): Contains service codes and clinical logic used in the
methodology, including episode triggers, exclusion categories, episode subgroups,
assigned items and services, and risk adjustors.

New cost measures may be submitted for consideration for use in the MIPS program using the
2025 Call for Measures and Activities process, which will be outlined on the QPP Resource
Library.
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Submission and Review Process
On an annual basis, CMS intends to host a public MVP development webinar to review the
MVP development criteria as well as the timeline and process to submit a candidate MVP.
Candidate MVPs can be submitted on a rolling basis throughout the year through the Call for
MVP process to be considered for potential inclusion in the upcoming notice of proposed
rulemaking and, if finalized, subsequent implementation beginning with the CY 2025
performance period/2027 MIPS payment year.
As MVP candidates are received, they will be reviewed and evaluated by CMS and its
contractors. CMS will use 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 evaluate the quality and cost
measures from a technical perspective to validate applicability to the clinician being measured
for performance. CMS will review all potential specialty-specific quality or cost measures
available in the MIPS inventory to ensure only the most appropriate measures are included in
the MVP candidate.
CMS may reach out to submitters of MVP candidates on an as-needed basis should questions
arise during the review process. Submitting an MVP candidate doesn’t guarantee it will be
considered or accepted for the rulemaking process. To ensure a fair and transparent
rulemaking process, CMS won’t communicate (to those who submit MVP candidates) whether
an MVP candidate has been approved, disapproved, or will be 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.
CY 2025 Final Rule text:
Submission and Review Process

MVP candidates can be submitted through the Call for MVPs process on a rolling basis
throughout the year and will be considered for potential inclusion in the upcoming notice of
proposed rulemaking. If finalized, implementation would begin with the CY 2026 performance
period/2028 MIPS payment year.
MVP candidates will be reviewed by CMS as they’re received. CMS will use the MVP
development criteria (see Appendix below) to determine if the MVP candidate is feasible.
CMS will also evaluate the quality and cost measures from a technical perspective to validate
applicability to the clinician being measured for performance. CMS will review all potential
specialty-specific quality or cost measures available in the MIPS inventory to ensure only the
most appropriate measures are included in the MVP candidate.
CMS may reach out to submitters of MVP candidates on an as-needed basis should questions
arise during the review process. Submitting an MVP candidate doesn’t guarantee it will be
considered or accepted for the rulemaking process. CMS won’t communicate the status of an
MVP candidate (i.e., approved, rejected, or considered for a future year) with those who
submitted the candidate prior to the publication of the proposed rule.
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Table 1: MVP Descriptive Information
Intent of Measurement

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CY 2025 Final Rule text:
Table 1: MVP Descriptive Information

What is the intent of the MVP?
Is the intent of the MVP the same at the individual
clinician and group level?
Are there opportunities to improve the quality of
care and value in the area being measured?
Why is the topic of measurement meaningful to
clinicians?
Does the MVP act as a vehicle to incrementally
phase clinicians into APMs? How so?
Is the MVP reportable by small and rural
practices? Does the MVP consider reporting
burden to those small and rural practices?
Which Meaningful Measure 2.0 Framework
Domain(s) does the MVP address?

Intent of
Measurement

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What is the intent of the MVP?
Is the intent of the MVP the same at the individual clinician and
group level?
Are there opportunities to improve the quality of care and value in
the area being measured?
Why is the topic of measurement meaningful to clinicians?
Does the MVP act as a vehicle to incrementally phase clinicians
into APMs? How so?
Is the MVP reportable by small and rural practices? Does the MVP
consider reporting burden to those small and rural practices?
Which Meaningful Measure health care priority does the MVP
address?

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CY 2024 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. At a minimum, Table 2A should include
measure/activity IDs, measure/activity titles, measure collection types, and rationale for
inclusion.
Generally, an MVP should include a sufficient number of quality measures and improvement
activities to allow MVP participants to select measures and activities to meet MIPS
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 represented within the MVP candidate may depend on their availability within MIPS.
• For example, the 2023 Advancing Care for Heart Disease MVP includes 14 quality
measures and 11 improvement activities. Cardiac disease can encompass several
conditions relative to heart care; 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.
CMS isn’t 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 (Table 2B and Table 2C) and is pre-filled
for each MVP candidate submission and can’t be changed.
Please refer to the Appendix below for further guidance regarding measure and activity
selection.
CY 2025 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. At a minimum, Table 2A should include
measure/activity IDs, measure/activity titles, measure collection types, and rationale for
inclusion. The number of rows included should reflect the number of measures/activities that
are necessary to describe the MVP candidate submission.
Generally, an MVP should include enough quality measures and improvement activities to allow
MVP participants to select measures and activities to meet MIPS requirements. The total
number of quality measures and activities represented within the MVP candidate may depend
on their availability within MIPS.
• For example, the 2024 Advancing Care for Heart Disease MVP includes 18 quality
measures and 14 improvement activities. Cardiac disease can encompass several
conditions relative to heart care; 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 1 cost measure relevant and applicable to the
MVP topic. The number of cost measures in an MVP may vary depending on the clinical topic of
the MVP.
The foundational layer of measures is included below (Table 2B and Table 2C) and is pre-filled
for each MVP candidate submission and can’t be changed.
Please refer to the Appendix below for further guidance regarding measure and activity
selection.
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CY 2024 Final Rule text:
Table 2C: Foundational Layer – Promoting Interoperability Measures
OBJECTIVE
MEASURE ID, TITLE, AND REQUIRED FOR
EXCLUSION
DESCRIPTION
PROMOTING
AVAILABLE
INTEROPERABILITY
CY 2025 Final Rule text:

ADDITIONAL
INFORMATION

Table 2C: Foundational Layer – Promoting Interoperability Measures
OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED

EXCLUSION
AVAILABLE

ADDITIONAL
INFORMATION

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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 they are relatable in
clinical topic, setting, and specialty (including nurse practitioners, physician assistants,
certified registered nurse anesthetists, and clinical social workers) to the cost measure(s)
and activities within the MVP?
o These quality measures should include appropriate settings and applicability to nonphysician practitioners (e.g., nurse practitioners, physician assistants, etc.).
• Have the quality measure numerators been assessed to ensure congruency 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 the general public to utilize our established pre-rulemaking processes,
such as the Call for Quality 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?
• For which collection types are the measures available?
• What role does each quality measure play in driving quality clinical care, improving
healthcare value, and addressing the health equity gap within the MVP?
• 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 2025 Final Rule text:
Quality Measures:
• Do the quality measures included in the MVP meet the existing quality measure inclusion
criteria? (For example, does the measure align with current clinical guidelines?)
• Have the quality measure denominators been evaluated to ensure they are relatable in
clinical topic, setting, and specialty (including nurse practitioners, physician assistants,
certified registered nurse anesthetists, and clinical social workers) to the cost measure(s)
and activities within the MVP?
o These quality measures should include appropriate settings and applicability to nonphysician practitioners (e.g., nurse practitioners, physician assistants, etc.).

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Have the quality measure numerators been assessed to ensure congruency 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 the interested parties to utilize our established pre-rulemaking processes,
such as the Call for Quality 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?
For which collection types are the measures available?
What role does each quality measure play in driving quality clinical care, improving
healthcare value, and addressing the health equity gap within the MVP?
To the extent feasible, specialty and sub-specialty specific quality measures are
incorporated into the MVP. Broadly applicable and/or cross-cutting quality measures may
be incorporated if relevant to the clinicians being measured.