CMS-10621 Appendix M1 (See Table 25): 2022 MVP Candidates: Instruc

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

The Centers for Medicare & Medicaid Services (CMS) invites interested stakeholders to submit
Merit-based 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.

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 should be focused on a given specialty, condition, and/or episode of care. CMS is
currently working to identify MVP development priorities and will publish a list of the identified
priorities for reference in the near future.
CMS is also interested in MVPs that measure the patient journey and care experience over time
and would like to explore how MVPs could best measure the value of and be used within a
multi-disciplinary, team-based care model.
CMS is committed to closing the health equity gap in CMS Clinician Quality Programs as
discussed in the final rule. Therefore, CMS encourages the implementation of health equitybased improvement activities within MVPs.
As noted in the calendar year (CY) 2021 and CY 2022 Physician Fee Schedule final rules, 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 2022 Final Rule Fact Sheet can be accessed on the MVP
website.
While MVP development is collaborative by nature, including having stakeholders work together
with other groups and with patients, ultimately CMS will determine if the MVP is appropriate and
responsive to CMS and Department of Health and Human Service (HHS) priorities, and if so,
what the timing for implementation of the MVP should be.
All MVPs, whether they are new or existing MVPs with updates, must undergo notice and
comment rulemaking and are subjected to the public comment period. And 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.

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We ask that all stakeholders keep in mind as they collaborate on and submit MVP candidates,
that CMS is considered the lead (and ultimately the owner) of all MVPs established through the
rulemaking process.

MVP Candidate Submission Instructions and Template
Introduction

These instructions identify the information that should be submitted, using the standardized
template below, by stakeholders who wish to have an MVP candidate considered by CMS for
potential implementation.
MVP candidates should include measures and activities from across the four performance
categories. The MVP candidate should include measures and activities across the quality, cost,
and improvement activities performance categories.
In the foundational layer, each MVP candidate includes the entire set of Promoting
Interoperability measures. Furthermore, the foundational layer includes 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.
Note: In this template, submitters do not need to submit the Promoting Interoperability
measures and the population health measures because they are required across all MVP
candidates and cannot be changed.
Please complete and submit both Table 1 and Table 2a of the template below for each intended
MVP candidate. If both tables are not complete, CMS will be unable 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.
- 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 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 of
this document.

MVP Candidate Content and Review Process

CMS encourages 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 in order 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.
Please view the current MIPS quality measures list and their associated specialty set and
measure properties in the 2021 MIPS Quality Measures List and 2021 Cross-Cutting Quality
Measures on the Quality Payment Program Resource Library for more information. Please view
the current QCDR measures list and measure properties in the 2021 Qualified Clinical Data
Registry (QCDR) Measure Specifications on the Quality Payment Program Resource Library for
more information.
• Measures that are currently outside the MIPS program need to follow the pre-rulemaking
process (i.e., Call for Measures and rulemaking) before they may be included in an
MVP.
• Qualified Clinical Data Registry (QDCR) measures may also be considered for inclusion
in an MVP as long as 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, stakeholders must 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, as finalized in the 2022 PFS Final Rule. This MVP
was developed to include outcome measures for this single specialty.
o If an outcome measure is not 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 as finalized in the 2022 PFS Final Rule. 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.
• If there are outcomes-based administrative claims measures that are relevant for a given
clinical topic, it may be included within the quality component of an MVP.
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 23 health
equity focused improvement activities in the current inventory: 2021 Improvement Activities
Inventory.

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New improvement activities may be submitted using the 2021 Call for Measures and Activities
process outlined on the Quality Payment Program Resource Library.
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 types of 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. Cost measure information
can be located on the MACRA Feedback Page.
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.
Candidate MVP submissions must be submitted no later than February 1, 2022, to be
considered for potential inclusion in the upcoming notice of proposed rulemaking and, if
finalized, subsequent implementation beginning with the CY 2023 performance period/2025
MIPS payment year.
As MVP candidates are received, they will be reviewed, vetted, 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 vet the quality and cost measures
from a technical perspective to validate that the coding in the quality measures and cost
measures include the clinician type being measured and whether all potential specialty-specific
quality measures or cost measures were considered, with the most appropriate included.
CMS may reach out to stakeholders on an as-needed basis should questions arise during the
review process. Please note that submitting an MVP candidate does not guarantee it will be
considered or 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)
whether an MVP candidate has been approved, disapproved, or is being considered for a future
year, prior to the publication of the proposed rule.

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Completed MVP candidate templates (inclusive of Table 1 and Table 2a) 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 is provided in Table 1 to provide further guidance.

TABLE 1: MVP DESCRIPTIVE INFORMATION
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?

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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?

Appropriateness

• 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 subspecialty?

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 were patients involved in the MVP
development process?
• To the extent feasible, does the MVP include
patient-reported outcome measures, patient
experience measures, and/or patient satisfaction
measures?

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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. Specifically, at a minimum, Table 2a
should include measure/activity IDs, measure/activity titles, measure collection types, and
rationales for inclusion.
Generally, an MVP should include a sufficient number of quality/cost measures and
improvement activities to allow MVP Participants to select measures and activities to meet the
reporting 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 available in an MVP would depend on the MVP structure.
For example, the Optimizing Chronic Disease Management MVP includes 9 quality measures
and 12 improvement activities. Chronic disease can broadly encompass several conditions;
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.
As CMS is not 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 (Tables 2b and 2c) and is pre-filled for
each MVP candidate submission and cannot be changed.
Please refer to the Appendix below for further guidance regarding measure and activity
selection.
TABLE 2A: QUALITY MEASURES, IMPROVEMENT ACTIVITIES, AND COST MEASURES
QUALITY MEASURES

IMPROVEMENT
ACTIVITIES

COST MEASURES

For each measure, provide:

For each activity, provide:

For each measure, provide:

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QUALITY MEASURES

IMPROVEMENT
ACTIVITIES

COST MEASURES

TABLE 2B: FOUNDATIONAL LAYER - POPULATION HEALTH MEASURES
QUALITY
#

MEASURE TITLE
AND DESCRIPTION

COLLECTION
TYPE

MEASURE
TYPE /
HIGH
PRIORITY

NQS DOMAIN

HEALTH CARE
PRIORITY

MEASURE
STEWARD

479

Hospital-Wide, 30Day, All-Cause
Unplanned
Readmission (HWR)
Rate for the MeritBased Incentive
Payment Program
(MIPS Groups)

Administrative
Claims

Outcome

Communicatio
n and Care
Coordination

Promote
Effective
Communication
& Coordination
of Care

CMS

484

Clinician and
Clinician Group
Risk-standardized
Hospital Admission
Rates for Patients
with Multiple
Chronic Conditions

Administrative
Claims

Outcome

Effective
Clinical Care

Promote
Effective
Prevention and
Treatment of
Chronic
Disease

CMS

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TABLE 2C: FOUNDATIONAL LAYER – PROMOTING INTEROPERABILITY MEASURES
OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

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.

No

Yes

Annual
requirement for
Promoting
Interoperability
submission but
not scored.

Protect
Patient
Health
Information

PI_PPHI_2: Safety Assurance Factors for
EHR Resilience Guide (SAFER Guide):
Conduct an annual self-assessment using
the High Priority Practices Guide at any
point during the calendar year in which the
performance period occurs.

No

Yes

Annual
requirement for
Promoting
Interoperability
submission but
not scored.

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

Yes

Yes

e-Prescribing

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.

No

No

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Bonus
Promoting
Interoperability
measure at this
time.

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

Provider to
Patient
Exchange

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
patient-authorized 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).

No

Yes

Health
Information
Exchange

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.

Yes

Yes

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ADDITIONAL
INFORMATION

The optional
PI_HIE_5:
Health
Information
Exchange (HIE)
Bi-Directional
Exchange
measure may
be reported as
an alternative
reporting option
to PI_HIE_1 and
PI_HIE_4 which
would allow an
eligible clinician
to attest to
participation in
bi-directional
exchange
through an HIE
using CEHRT
functionality.

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

Health
Information
Exchange

PI_HIE_4: Support Electronic Referral
Loops by Receiving and Reconciling
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.

Yes

Yes

The optional
PI_HIE_5:
Health
Information
Exchange (HIE)
Bi-Directional
Exchange
measure may
be reported as
an alternative
reporting option
to PI_HIE_1 and
PI_HIE_4 which
would allow an
eligible clinician
to attest to
participation in
bi-directional
exchange
through an HIE
using CEHRT
functionality.

Health
Information
Exchange

PI_HIE_5: Health Information Exchange
(HIE) Bi-Directional Exchange:
The MIPS eligible clinician or group must
attest that they engage in bidirectional
exchange with an HIE to support transitions
of care.

No

Yes

This measure is
an optional
alternative
Health
Information
Exchange (HIE)
bi-directional
exchange
measure and
may be reported
as an alternative
reporting option
in place of
PI_HIE_1 and
PI_HIE_4.

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OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

Public Health
and Clinical
Data
Exchange

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.

No

No

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.

No

No

Bonus
Promoting
Interoperability
measure at this
time.

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.

No

No

Bonus
Promoting
Interoperability
measure at this
time.

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ADDITIONAL
INFORMATION

Bonus
Promoting
Interoperability
measure at this
time.

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?
• 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 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, improving value, and
addressing the health equity gap 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? Provide a rationale as to why each improvement activity was included.
• 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?
• To the extent feasible, does the MVP include improvement activities that can be
conducted using CEHRT functions? The use of improvement activities that specify the use
of technologies will help to further align with the CEHRT requirement under the Promoting
Interoperability performance category.
• 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)?

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Cost Measures:
• What role does the cost measure(s) play in driving quality care and improving value within
the MVP? Provide a rationale as to why each cost measure was selected.
• 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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