2023 MIPS Quality Measure Changes

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).

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
- #469: Functional Status After Lumbar Fusion [page 2]
- #473: Leg Pain After Lumbar Fusion
2 measures were removed from traditional MIPS, but were retained for use in current and future MVPs (MIPS Value Pathways)
- #110: Preventive Care and Screening: Influenza Immunization [page 2]
- #111: Pneumococcal Vaccination Status for Older Adults [page 2]
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:

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):
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)
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: