Merge pull request #841 from CMSgov/QPPA-9220

QPPA-9220: update PY25 IA measures

measures/2025/measures-data.json

@@ -1,21 +1,4 @@
 [
-  {
-    "category": "ia",
-    "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record",
-    "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:•\tExpanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);•\tUse of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or•\tProvision of same-day or next-day access to a MIPS eligible clinician, group or care team when needed for urgent care or transition management.",
-    "measureId": "IA_EPA_1",
-    "metricType": "boolean",
-    "firstPerformanceYear": 2017,
-    "lastPerformanceYear": null,
-    "weight": "high",
-    "subcategoryId": "expandedPracticeAccess",
-    "allowedPrograms": [
-      "mips",
-      "app1",
-      "G0056",
-      "M0004"
-    ]
-  },
   {
     "category": "ia",
     "title": "Use of telehealth services that expand practice access",
@@ -1155,21 +1138,6 @@
       "app1"
     ]
   },
-  {
-    "category": "ia",
-    "title": "Invasive Procedure or Surgery Anticoagulation Medication Management",
-    "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.",
-    "measureId": "IA_PSPA_27",
-    "metricType": "boolean",
-    "firstPerformanceYear": 2018,
-    "lastPerformanceYear": null,
-    "weight": "medium",
-    "subcategoryId": "patientSafetyAndPracticeAssessment",
-    "allowedPrograms": [
-      "mips",
-      "app1"
-    ]
-  },
   {
     "category": "ia",
     "title": "Completion of an Accredited Safety or Quality Improvement Program",
@@ -1411,36 +1379,6 @@
       "app1"
     ]
   },
-  {
-    "category": "ia",
-    "title": "Implementation of a Personal Protective Equipment (PPE) Plan",
-    "description": "Implement a plan to acquire, store, maintain, and replenish supplies of personal protective equipment (PPE) for all clinicians or other staff who are in physical proximity to patients.In accordance with guidance from the Centers for Disease Control and Prevention (CDC) the PPE plan should address:•\tConventional capacity: PPE controls that should be implemented in general infection prevention and control plans in healthcare settings, including training in proper PPE use.•\tContingency capacity: actions that may be used temporarily during periods of expected PPE shortages.•\tCrisis capacity: strategies that may need to be considered during periods of known PPE shortages.The PPE plan should address all of the following types of PPE:•\tStandard precautions (e.g., hand hygiene, prevention of needle-stick or sharps injuries, safe waste management, cleaning and disinfection of the environment)•\tEye protection•\tGowns (including coveralls or aprons)•\tGloves•\tFacemasks•\tRespirators (including N95 respirators)",
-    "measureId": "IA_ERP_4",
-    "metricType": "boolean",
-    "firstPerformanceYear": 2022,
-    "lastPerformanceYear": null,
-    "weight": "medium",
-    "subcategoryId": "emergencyResponseAndPreparedness",
-    "allowedPrograms": [
-      "mips",
-      "app1"
-    ]
-  },
-  {
-    "category": "ia",
-    "title": "Implementation of a Laboratory Preparedness Plan",
-    "description": "Develop, implement, update, and maintain a preparedness plan for a laboratory intended to support continued or expanded patient care during COVID-19 or another public health emergency. The plan should address how the laboratory would maintain or expand patient access to health care services to improve beneficiary health outcomes and reduce healthcare disparities. For laboratories without a preparedness plan, MIPS eligible clinicians would meet with stakeholders, record minutes, and document a preparedness plan, as needed. The laboratory must then implement the steps identified in the plan and maintain them. For laboratories with existing preparedness plans, MIPS eligible clinicians should review, revise, or update the plan as necessary to meet the needs of the current PHE, implement new procedures, and maintain the plan.Maintenance of the plan in this activity could include additional hazard assessments, drills, training, and/or developing checklists to facilitate execution of the plan. Participation in debriefings to evaluate the effectiveness of plans are additional examples of engagement in this activity.",
-    "measureId": "IA_ERP_5",
-    "metricType": "boolean",
-    "firstPerformanceYear": 2022,
-    "lastPerformanceYear": null,
-    "weight": "medium",
-    "subcategoryId": "emergencyResponseAndPreparedness",
-    "allowedPrograms": [
-      "mips",
-      "app1"
-    ]
-  },
   {
     "category": "ia",
     "title": "Diabetes screening",
@@ -1680,36 +1618,6 @@
       "app1"
     ]
   },
-  {
-    "category": "ia",
-    "title": "COVID-19 Vaccine Achievement for Practice Staff",
-    "description": "Demonstrate that the MIPS eligible clinician’s practice has maintained or achieved a rate of 100% of office staff staying up to date with COVID vaccines according to the Center for Disease Control and Prevention (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html). Please note that those who are determined to have a medical contraindication specified by CDC recommendations are excluded from this activity.",
-    "measureId": "IA_ERP_6",
-    "metricType": "boolean",
-    "firstPerformanceYear": 2023,
-    "lastPerformanceYear": null,
-    "weight": "medium",
-    "subcategoryId": "emergencyResponseAndPreparedness",
-    "allowedPrograms": [
-      "mips",
-      "app1",
-      "G0053",
-      "G0054",
-      "G0055",
-      "G0057",
-      "G0058",
-      "G0059",
-      "M0001",
-      "M0002",
-      "M0003",
-      "M0005",
-      "M1366",
-      "M1367",
-      "M1368",
-      "M1369",
-      "M1370"
-    ]
-  },
   {
     "category": "ia",
     "title": "Practice Improvements that Engage Community Resources to Address Drivers of Health",
@@ -1833,6 +1741,42 @@
       "M1370"
     ]
   },
+  {
+    "category": "ia",
+    "title": "Implementation of Protocols and Provision of Resources to Increase Lung Cancer Screening Uptake",
+    "description": "Establish a process or procedure to increase rates of lung cancer screening through one or more of the following interventions:\n•Implementation of protocols that support enhanced documentation methods to identify eligible patients for lung cancer screening. \n++ Example: A practice could embed electronic health record (EHR) prompts to flag insufficient patient smoking history (for example, total pack-years) and increase practice awareness around patient eligibility for screening\n++ Example: A practice could implement documentation processes or procedures (for example, retrospective chart review, lung cancer screening eligibility questionnaire) to improve patient lung cancer screening eligibility data in the medical record\n•Development of a patient outreach and activation plan consisting of educational materials and resources for patients at high-risk of lung cancer for improved patient engagement and decision-making. \n++ Example: Providers or clinic staff could provide culturally and linguistically appropriate patient-directed educational or care navigation materials related to lung cancer screening, eligibility criteria for low-dose computed tomography (LDCT), and the purpose and benefits of screening\n++ Example: Providers or clinic staff could provide tools to prepare patients for shared decision-making (SDM) clinical encounters and promote patient/provider communication on lung cancer screening decision-making\n•Establishment of a navigation program to improve uptake and adherence of lung cancer screening and increase rates of LDCT referral completion. \n++ Example: A practice could designate and train existing clinic staff or hire an additional staff member to counsel patients on the importance of lung cancer screening and refer them to existing resources (for example, transportation assistance, translator, financial services, appointment scheduling) to support ability to obtain LDCT\n++ Example: A practice could create a process to follow up with referred patients via telephone reminders or virtual notifications (for example, email, patient charts)",
+    "measureId": "IA_PM_24",
+    "metricType": "boolean",
+    "firstPerformanceYear": 2025,
+    "lastPerformanceYear": null,
+    "weight": null,
+    "subcategoryId": "populationManagement",
+    "allowedPrograms": []
+  },
+  {
+    "category": "ia",
+    "title": "Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk",
+    "description": "Implement standardized, evidence-based cardiovascular disease risk assessment and care management for a defined population in the clinician’s practice.\nThe clinician or clinician group will apply standardized risk assessment and care management to a broad, clinician-defined patient population in the practice. The population can be defined by 1) patient age and/or atherosclerotic cardiovascular disease (ASCVD) risk factors; or 2) the constraints of the risk assessment tool (for example, the American College of Cardiology (ACC)/American Heart Association (AHA) ASCVD Risk Calculator is validated for patients over age 40).\nThe results of screening and the plan for treatment and follow up will be documented using a standardized method in the patient’s medical record. Care management plan and follow up intervals will be influenced by the degree of patient risk.\nCardiovascular care management should be defined by risk assessment and lead to the development of individualized care plans with specific goals. Shared decision making should be part of the development of every patient care plan.",
+    "measureId": "IA_PM_25",
+    "metricType": "boolean",
+    "firstPerformanceYear": 2025,
+    "lastPerformanceYear": null,
+    "weight": null,
+    "subcategoryId": "populationManagement",
+    "allowedPrograms": []
+  },
+  {
+    "category": "ia",
+    "title": "Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B",
+    "description": "Demonstrate that the MIPS eligible clinician’s practice has achieved and/or maintained a vaccination rate of 60 percent of clinical practice staff for COVID-19, and 80 percent for influenza. Demonstrate vaccination, immunity, or non-responder status to hepatitis B for 95 percent of clinical practice staff. Vaccination recommendations are from Centers for Disease Control and Prevention; staff with contraindications to the vaccinations, as determined by the CDC, are excluded from the requirements.\nVaccines and Immunizations | CDC.",
+    "measureId": "IA_PM_26",
+    "metricType": "boolean",
+    "firstPerformanceYear": 2023,
+    "lastPerformanceYear": null,
+    "weight": null,
+    "subcategoryId": "populationManagement",
+    "allowedPrograms": []
+  },
   {
     "category": "pi",
     "measureId": "PI_PPHI_1",