MIPS for a small practice

This is a later response, and Dr. Freedman expertly answered your questions, but I thought I would add my 0.02. I downloaded the entire list of IA (improvement activities) and there are many that you are probably doing already. Dr. Freedman listed the ones APMA culled out of the CMS list......You have to attest to only ONE for a 90 day period.

For quality measures, you have to report 6......the reporting period is the entire year. If you are reporting via registry, or anything else other than the CLAIMS method, you have to report on EVERY patient (not just Medicare patients). If you report via CLAIMS method (that is, putting in codes in your claims....) then you only have to report on standard red-white-blue MEDICARE patients.

Another note, Medicare has a PODIATRY SET of quality measures. If you choose to report on their 6 measures, and you report them via claims, then you only have to report on TWO of them, since the other four in the podiatry set CANNOT be reported by claims method (and since you choose to report via claims, you'd be exempt from the other 4).

According to information improvement activities (IA) for 2025 for a small practice less than 15 requires you to attest to one activity which will yield your points. The reporting period for improvement activity must be a 90 day continuous. To meet this, the last start date for performing this in 2025 would be October 3, 2025 to end on December 31, 2025. Per the information, only need to attest to the activities to receive credit submission of supporting documentation is not required, and this can be done directly from the EHR if it allows it or through your registry.

The following are a list provided by APMA for IA in 2025:

1. Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop

2. Implementation of Improvements that Contribute to More Timely Communication of Test Results

3. Regularly Assess Patient Experience of Care and Follow Up on Findings

4. Use of Decision Support and Standardized Treatment Protocols

5. Implementation of Fall Screening and Assessment Programs

6. CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain

7. Completion of CDC Training on Antibiotic Stewardship

8. Enhance Engagement of Medicaid and Other Underserved Populations

9. Use of Telehealth Services that Expand Practice Access

10. Collection and Use of Patient Experience and Satisfaction Data on Access

11. Trackingrof Clinician's Relationship to and Responsibility for a Patient by Reporting MACRA

Patient Relationship Codes

12. Promoting Clinician Well-Being

13. Completion of the AMA STEPS Forward program

14. Completion of an Accredited Safety or Quality Improvement Program

15. Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B

16. Create and Implement an Anti-Racism Plan

17. Create and Implement a Language Access Plan

18. Create and Implement a Plan to Improve Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients

In ModMed, quality measures that I know you currently can check off include: hypertension 317, each E&M take patients blood pressure eavh visit record if normal no action but if out of parameters select the mips nutition and quality plan preventative care option to get credit. There is the measure 47 advanced care planning once yearly, you merely select a yes or no, add the name of the healthcare proxy and their phone number if it’s not available, enter 111–1 11–1111. This measure only occurs when someone is 65 and older, and the other part is the living will part which is part of advanced care planning need to be selected yes or no. Also, in Mod Med, you can select the diabetes measures 126 and 127 which include the neurological review and the shoe review for the patients whether appropriate or not once per year. Those two measures are also part of the modmed quality measure platform. There are measures 226 Tobacco use and cessation required for age of patients 12 years and older

Letting patient know verbally that smoking is not good for them and leads to prolong healing, heart issues, etc. satisfies this; and measure 155 falls plan of care. this is done at their initial visit and documenting have they fallen, do you ever feel unsteady, do you use an assist device, do you have a history of foot drop? You must provide with a balance, strength, and gait training instruction form to meet this requirement .

This provides you a 2025 list of the six measures that you would need to perform to meet quality measures in ModMed.

modMED

Registry

2024- took the MIPS extreme Uncontrollable Circumstances (EUC) Exception

Before we can answer, you are a small practice, are you using a registry and if so which one? Or are you using billing to report MIPS codes?

What did you use in 2024 and which did you plan in 2025?