Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Can

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

Appendix M MVP Development Standardized Template

2022 >> Nomination of MVPs (SS-A Table 28)

OMB: 0938-1314

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STAKEHOLDER SUBMISSIONS OF MIPS
VALUE PATHWAYS (MVP) CANDIDATES:
INSTRUCTIONS AND TEMPLATE
Background
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.

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 rule, 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.

MVP Candidate Submission Instructions and Template
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.

MVP Candidate Content and Review Process

CMS encourages submissions to include measures and improvement activities that are
currently available in MIPS. To view all measures and 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 in order to be considered for inclusion
within an MVP.
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.
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.
Cost Measures
The current inventory of cost measures covers different types of care. Procedural episodebased cost measures apply to specialties, such as orthopedic surgeons who 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

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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.
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 discuss 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) final decisions regarding MVP proposals in rulemaking.
Completed MVP candidate templates (inclusive of Table 1 and Table 2) should be
submitted to [email protected] for CMS evaluation.

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.

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TABLE 1: MVP DESCRIPTIVE INFORMATION
General Topic

Information Required

MVP Name

 Provide title that succinctly describes the proposed
MVP. CMS encourages a title suggesting action (for
example: Improving Disease Prevention
Management).

Primary/Alternative Contact
Names

 Primary point of contact: Provide full name,
organization name, email, and phone number.
 One or more alternative points of contact: Provide full
name, email, and phone number.

Intent of Measurement

 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 Domain(s) does the MVP
address?

Measure and Activity
Linkages with the MVP

 How do the measures and activities within the
proposed MVP link to one another? (For example, do
the measures and activities assess different
dimensions of care provided by the clinician?).
Linkages between measures and activities should be
considered as complementary relationships.
 Are the measures and activities related or a part of the
care cycle or continuum of care offered by the
clinicians?
 Why are the chosen measures and activities most
meaningful to the specialty?

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General Topic
Appropriateness

Information Required
 Is the MVP reportable by multiple specialties? If so,
has the MVP been developed collaboratively across
specialties?
 Are the measures clinically appropriate for the
clinicians being measured?
 Do the measures capture a clinically definable
population of clinicians and patients?
 Do the measures capture the care settings of the
clinicians being measured?
 Prior to incorporating a measure in an MVP, is the
measure specification evaluated, to ensure that the
measure is inclusive of the specialty or sub-specialty?

Comprehensibility

 Is the MVP comprehensive and understandable by the
clinician or group?
 Is the MVP comprehensive and understandable by
patients?

Incorporation of the Patient
Voice

 Does the MVP take into consideration the patient
voice? How?
 Does the MVP take into consideration patients in rural
and underserved areas?
 How are patients involved in the MVP development
process?
 To the extent feasible, does the MVP include patientreported outcome measures, patient experience
measures, and/or patient satisfaction measures?

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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.
TABLE 2A: QUALITY MEASURES, IMPROVEMENT ACTIVITIES, AND COST MEASURES
Quality Measures

Improvement Activities

Cost Measures

For each activity, provide:

For each measure,
provide:



















































For each measure,
provide:







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TABLE 2B: FOUNDATIONAL LAYER - POPULATION HEALTH MEASURE
Quality
#

TBD

Measure Title
and Description
Hospital-Wide, 30-Day, All-Cause Unplanned
Readmission (HWR) Rate for the Merit-Based
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, cardio-respiratory,
cardiovascular, and neurology.

Collection
Type

Administrative
Claims

Measure
Type /
High
Priority

NQS
Domain

Communicati
on and Care
Coordination

Outcome

Health

Measure
Steward

Care
Priority

Promote
Effective
Communication
& Coordination
of Care

Yale
University

ABLE 2C: FOUNDATION LAYER - PROMOTING INTEROPERABILITY MEASURES
Objective

Measure ID, Title, and Description

Protect Patient
Health
Information

PI_PPHI_1: Security Risk Analysis:
Conduct or review a security risk 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.

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Exclusion
Available

Required Additional
for PI
Information

No

Yes

Annual
requirement for PI
submission but
not scored.

Objective

Measure ID, Title, and Description

e-Prescribing

PI_EP_1: e-Prescribing:
At least one permissible prescription written by the MIPS eligible
clinician is queried for a drug formulary and transmitted
electronically using CEHRT.
PI_EP_2: Query of Prescription Drug Monitoring Program
(PDMP):
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 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).
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.
PI_HIE_4: Support Electronic Referral Loops by Receiving and
Incorporating 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.

e-Prescribing

Provider to
Patient
Exchange

Health
Information
Exchange

Health
Information
Exchange

8

Exclusion
Available

Required Additional
for PI
Information

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Bonus PI measure
at this time

Exclusion
Available

Required Additional
for PI
Information

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).

Yes

Yes

Public Health
and Clinical
Data
Exchange

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

Public Health
and Clinical
Data
Exchange

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.

Yes

Yes

Public Health
and Clinical
Data
Exchange

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.

Yes

Yes

Public Health
and Clinical
Data
Exchange

PI_PHCDRR_5: Clinical Data Registry Reporting:
The MIPS eligible clinician is in active engagement to submit data to
a clinical data registry.

Yes

Yes

Objective

Measure ID, Title, and Description

Public Health
and Clinical
Data
Exchange

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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
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

Appendix
Additional Guidance and Considerations When Submitting an MVP Candidate:

Consideration should be given to the following criteria when developing rationales for including
measures and activities in your MVP candidate submission:
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?
a. 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.
Improvement Activities:
 What role does the improvement activity play in driving quality care and improving value
within the MVP?
 Describe how the improvement activity can be used to improve the quality of performance
in clinical practices for those clinicians who would report this MVP.
 Does the improvement activity complement and/or supplement the quality action of the
measures in the MVP, rather than duplicate it?
 If there are no relevant specialty or sub-specialty specific improvement activities, does the
MVP includes broadly applicable improvement activities (that is applicable to the clinician
type)?
Cost Measures:
 What role does the cost measure(s) play in driving quality care and improving value within
the MVP?
 How does the selected cost measure(s) relate to other measures and activities in other
performance categories?
 If there are not relevant cost measures for specific types of care being provided (for
example, conditions or procedures), does the MVP include broadly applicable cost
measures (that are applicable to the type of clinician)?
 What additional cost measures should be prioritized for future development and inclusion
in the MVP?

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File TitleStakeholder Submissions of MVP Candidates: Instructions and Template
AuthorCMS
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