Below is a summary breakdown of the critical steps to comply with the MACRA QPP MIPS program as a Vein Center practice…


Breakdown of Merit-based Incentive Payment System (MIPS)



Breakdown of the Three Categories:


I.  Quality Measures (PQRS 60%)Select 6 Measures with One Outcome Measure

Below are the six that we recommend for Vein:

1.     Documentation of Current Medications in the Medical Record

2.     Closing the Referral Loop: Receipt of Specialist Report

3.     Varicose Vein Treatment with Saphenous Ablation: Outcome Survey (Outcome Measure)

4.     Surgical Site Infection (SSI) (Outcome Measure)

5.     Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

6.     Controlling High Blood Pressure


II. Advancing Care Information Measures (Meaningful Use 25%)

1.     Security Risk Analysis

2.     e-Prescribing

3.     Provide Patient Access

4.     Send Summary of Care

5.     Request/Accept Summary of Care

6.     Health Information Exchange

7.     Immunization Registry Reporting

8.     Medication Reconciliation

9.     Patient-Specific Education

10.  Secure Messaging

11.  Specialized Registry Reporting

12.  View, Download, or Transmit (VDT)


III. Improvement Activities Measures (New Category 15%)Complete at least 4, if your practice has fewer than 15 providers, you only need to select 2.

There are over 93 Activities that practices can select from. Here are a few from the list that we thought were good ones. You can view the listing of activities here:

1.     Annual registration in the Prescription Drug Monitoring Program

2.     Consultation of the Prescription Drug Monitoring program

3.     Implementation of fall screening and assessment programs

4.     Use of decision support and standardized treatment protocols

5.     Use of patient safety tools

6.     Implementation of improvements that contribute to more timely communication of test results

7.     Implementation of use of specialist reports back to referring clinician or group to close referral loop

8.     Practice improvements for bilateral exchange of patient information

9.     Regular training in care coordination

10.  Engagement of patients through implementation of improvements in patient portal

11.  Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.

12.  Use of certified EHR to capture patient reported outcomes



Quality Payment Program:

QPP Executive Summary:

QPP Final Rule:

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