Crosswalk: Appendix K1

MVP Development Standardized Template
CY 2022 Final versus CY 2023 Final
Burden impact: The changes to the MVP Development Standardized Template reflect
finalization of proposals, language updates, and additional text added from the CY 2022
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program to the CY 2023
Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program. The result is an
estimated change of zero hours.
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CY 2022 Final Rule text:

Purpose

The Centers for Medicare & Medicaid Services (CMS) invites stakeholders to submit Meritbased Incentive Payment System (MIPS) Value Pathways (MVP) candidates for CMS
consideration and potential implementation through future rulemaking.

CY 2023 Final Rule text:

Purpose

The Centers for Medicare & Medicaid Services (CMS) invites the general public to submit Meritbased Incentive Payment System (MIPS) Value Pathways (MVP) candidates for CMS
consideration and potential implementation through future rulemaking.

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CY 2022 Final Rule text:

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.
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.
CY 2023 Final Rule text:

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 has
identified a list of specialties/clinical topics that are considered priorities for MVP development
and encourages the general public to submit MVPs that incorporate the identified specialties.
Please review the MVP Needs and Priorities document found within the MVPs Development
Resources ZIP file for additional information, available on the MVP Candidate Development &
Submission webpage.
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.
As noted in the 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 2023 Final Rule Fact Sheet can be accessed on the MVP website.
While MVP development is collaborative by nature, including having the general public 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 Services (HHS)
priorities, and if so, what the timing for implementation of the MVP should be.
In the CY 2023 PFS Final Rule, we finalized the modification of the MVP development process
to include a 30-day comment period for the general public to submit feedback on candidate

MVPs prior to potentially including an MVP in a notice of proposed rulemaking. All MVPs,
whether they are new or existing MVPs with updates, must undergo notice and comment
rulemaking and are subject to the public comment period. 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.
We ask that the general public 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.
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CY 2022 Final Rule text:

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.
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 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.
CY 2023 Final Rule text:

Introduction

These instructions identify the information that should be submitted, using the standardized
template below, by the general public who wish to have an MVP candidate considered by CMS
for potential implementation.
MVP candidates include measures and activities from across the four performance categories.
MVP candidate submissions by the general public 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 performance category 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 don’t need to submit the Promoting Interoperability
performance category measures or the population health measures. The Promoting
Interoperability performance category measure specifications are available on the Promoting
Interoperability Performance Category Webpage. These foundational layer measures are
prefilled because they are required across all MVP candidates and can’t be changed.
Please complete and submit both Table 1 and Table 2a of the template below for each
intended MVP candidate. Both tables must be completed for CMS 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.
o Please note that CMS isn’t 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.
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CY 2022 Final Rule text:

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.
CY 2023 Final Rule text:

MVP Candidate Content and Review Process

CMS encourages MVP 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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CY 2022 Final Rule text:
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.

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.
o

•

CY 2023 Final Rule text:
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, including associated specialty set(s) and
measure properties in the 2022 MIPS Quality Measures List and 2022 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 2022 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.
• QDCR measures may also be considered for inclusion in an MVP if 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, the general public should 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 2023 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 2023 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.

•

Outcome-based administrative claims measures may be included to support the quality
performance category of an MVP candidate.

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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.
New improvement activities may be submitted using the 2021 Call for Measures and Activities
process outlined on the Quality Payment Program Resource Library.
CY 2023 Final Rule text:
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 27 health
equity focused improvement activities in the current inventory: 2022 Improvement Activities
Inventory.
New improvement activities may be submitted using the 2022 Call for Measures and Activities
process outlined on the Quality Payment Program Resource Library.
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CY 2022 Final Rule text:
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.
CY 2023 Final Rule text:
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.
New cost measures may be submitted for consideration for use in the MIPS program using the
2022 Call for Measures and Activities process outlined on the Quality Payment Program
Resource Library.
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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.
Completed MVP candidate templates (inclusive of Table 1 and Table 2a) should be
submitted to PIMMSMVPSupport@gdit.com for CMS evaluation.
CY 2023 Final Rule text:
Submission and Review Process
On an annual basis, CMS intends to host a public-facing MVP development webinar to remind
the general public of MVP development criteria as well as the timeline and process to submit a
candidate MVP.
Candidate MVP submissions can be submitted on a rolling basis throughout the year through
the Call for MVP process to be considered for potential inclusion in the upcoming notice of
proposed rulemaking and, if finalized, subsequent implementation beginning with the CY 2024
performance period/2026 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 applicability to the clinician being measured for
performance. In addition, CMS will review all potential specialty-specific quality or cost
measures available in the MIPS inventory to ensure only the most appropriate measures are
included in the MVP candidate.
CMS may reach out to submitters of MVP candidates 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 won’t communicate (to those who submit MVP
candidates) whether an MVP candidate has been approved, disapproved, or will be considered
for a future year, prior to the publication of the proposed rule.
Completed MVP candidate templates (inclusive of Table 1 and Table 2a) should be
submitted to PIMMSMVPSupport@gdit.com for CMS evaluation.
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CY 2022 Final Rule text:
TABLE 1: MVP DESCRIPTIVE INFORMATION
• MVP Name

Primary/Alternative Contact Names

• Intent of Measurement

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

Appropriateness

Comprehensibility

Incorporation of the Patient Voice

• 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?
• 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?
• Is the MVP comprehensive and understandable by
the clinician or group?
• Is the MVP comprehensive and understandable by
patients?
• 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 patientreported outcome measures, patient experience
measures, and/or patient satisfaction measures?

CY 2023 Final Rule text:
TABLE 1: MVP DESCRIPTIVE INFORMATION
MVP Name

•
•

Primary/Alternative Contact
Names

•
•

Intent of Measurement

•
•
•
•
•
•

•

Measure and Activity Linkages
with the MVP

•

•

•

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

•

•
•
•
•

Comprehensibility

•
•

Incorporation of the Patient Voice

•
•
•

•

Is the MVP candidate developed for multiple
specialties to report? 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?
Is the MVP comprehensive and understandable by
the clinician or group?
Is the MVP comprehensive and understandable by
patients?
Does the MVP take into consideration the patient
voice? How?
Does the MVP take into consideration patients in
rural and underserved areas?
Were patients involved in the MVP development
process? If so, how was their voice included in
development of the MVP candidate?
To the extent feasible, does the MVP include
patient-reported outcome measures, patient
experience measures, and/or patient satisfaction
measures?

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CY 2022 Final Rule text:
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.
CY 2023 Final Rule text:

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
rationale for inclusion.
Generally, an MVP should include a sufficient number of quality measures and improvement
activities to allow MVP participants to select measures and activities to meet MIPS
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 represented within the MVP candidate may depend on availability within MIPS.
• For example, the Optimizing Chronic Disease Management MVP includes 9 quality
measures and 15 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 can’t be changed.

Please refer to the Appendix below for further guidance regarding measure and activity
selection.
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CY 2022 Final Rule text:
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:

No

Yes

Annual
requirement for
Promoting
Interoperability
submission but
not scored.

Annual
requirement for
Promoting
Interoperability
submission but
not scored.

• 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.

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

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

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

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

Bonus
Promoting
Interoperability
measure at this
time.

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

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

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

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.

OBJECTIVE

MEASURE ID, TITLE, AND DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

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.

Bonus
Promoting
Interoperability
measure at this
time.

CY 2023 Final Rule text
TABLE 2C: FOUNDATIONAL LAYER – PROMOTING INTEROPERABILITY MEASURES
OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

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

Protect
Patient Health
Information

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

No

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY
Yes

Yes

ADDITIONAL
INFORMATION

Annual requirement for
Promoting
Interoperability
submission but not
scored.

Annual requirement for
Promoting
Interoperability
submission but not
scored.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

Attestation

PI_ONCDIR_1: ONC-Direct
Review Attestation:

No

Yes

I attest that I - (1) Acknowledge the
requirement to cooperate in good
faith with ONC direct review of his
or her health information
technology certified under the ONC
Health IT Certification Program if a
request to assist in ONC direct
review is received; and (2) If
requested, cooperated in good faith
with ONC direct review of his or her
health information technology
certified under the ONC Health IT
Certification Program as authorized
by 45 CFR part 170, subpart E, to
the extent that such technology
meets (or can be used to meet) the
definition of CEHRT, including by
permitting timely access to such
technology and demonstrating its
capabilities as implemented and
used by the MIPS eligible clinician
in the field.
Attestation

PI_INFBLO_2: Actions to Limit or
Restrict Compatibility or
Interoperability of CEHRT:
I attest to CMS that I did not
knowingly and willfully take action
(such as to disable functionality) to
limit or restrict the compatibility or
interoperability of certified EHR
technology.

No

Yes

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

ADDITIONAL
INFORMATION

Annual requirement for
Promoting
Interoperability
submission but not
scored.

Annual requirement for
Promoting
Interoperability
submission but not
scored.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

e-Prescribing

PI_EP_2: Query of Prescription
Drug Monitoring Program
(PDMP):
For at least one Schedule II opioid
or Schedule III or IV drug
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.

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 patientauthorized 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).

EXCLUSION
AVAILABLE

Yes

No

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY
Yes

Yes

ADDITIONAL
INFORMATION

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

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

The optional PI_HIE_5 or
PI_HIE_6 Health
Information Exchange
measure may be reported
as an alternative reporting
option to PI_HIE_1 and
PI_HIE_4.

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 or
PI_HIE_6 Health
Information Exchange
measure may be reported
as an alternative reporting
option to PI_HIE_1 and
PI_HIE_4.

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
measure and may be
reported as an alternative
reporting option in place
of PI_HIE_1 and
PI_HIE_4 OR PI_HIE_6.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

Health
Information
Exchange

PI_HIE_6: Enabling Exchange
Under TEFCA:

No

Yes

This measure is an
optional alternative
Health Information
Exchange measure and
may be reported as an
alternative reporting
option in place of
PI_HIE_1 and PI_HIE_4
OR PI_HIE_5.

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

Provide eligible clinicians with the
opportunity to earn credit for the
Health Information exchange
objective if they: are a signatory to
a “Framework Agreement” as that
term is defined in the Common
Agreement; enable secure, bidirectional exchange of information
to occur for all unique patients of
eligible clinicians, and all unique
patient records stored or
maintained in the EHR; and use
the functions of CEHRT to support
bidirectional exchange.

Bonus Promoting
Interoperability measure
at this time.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

EXCLUSION
AVAILABLE

REQUIRED
FOR
PROMOTING
INTEROPERA
BILITY

ADDITIONAL
INFORMATION

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.

*****
Change #12:
Location: Page 13
Reason for Change:
Language updates
CY 2022 Final Rule text:
Appendix: 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.

CY 2023 Final Rule text:
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 they are applicable to
the cost measure(s) and activities within the MVP?
• Have the quality measure numerators been assessed to ensure congruency 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 the general public to utilize our established pre-rulemaking processes,
such as the Call for Quality 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?
• For which collection types are the measures available?
• What role does each quality measure play in driving quality clinical care, improving
healthcare value, and addressing the health equity gap within the MVP?
• 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.
*****
Change #13:
Location: Page 14
Reason for Change:
Language updates
CY 2022 Final Rule text:
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?

CY 2023 Final Rule text:
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 do the included cost measure(s) relate to quality measures and activities included in
the MVP?
• Are the included cost measures relevant to the specific types of care (for example,
conditions or procedures) and clinicians (for example, specialties or subspecialties)
intended to be assessed by the MVP?
*****