Appendix J1 2024 MVP Candidates: Instructions and Template

SUBMITTING MIPS VALUE PATHWAYS (MVP)
CANDIDATES: INSTRUCTIONS AND TEMPLATE
Background
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.
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 provide a pathway for clinicians to report on an applicable clinical topic based on their
specialty, their medical condition focus, or the setting in which they provide patient 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.
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 can be found on the MVP Candidate Development &
Submission webpage.
While stakeholder feedback in MVP development is appreciated, ultimately CMS will determine
if a given MVP candidate will move forward through rulemaking. CMS owns all MVPs that are
established through notice and comment rulemaking. CMS will determine if the MVP is
appropriate and responsive to the needs and priorities of the Agency, Department, and
Administration. In addition to determining if an MVP candidate aligns with programmatic needs,
CMS will also determine when an MVP candidate is ready for proposal through rulemaking for
future implementation.
In the CY 2023 PFS Final Rule, we finalized the modification of the MVP development process
to include a 30-day feedback 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.

1

MVP Candidate Submission Instructions and Template
Introduction

These instructions identify the information the general public should submit, using the
standardized template below, if they 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 should include measures and activities across the quality, cost,
and improvement activities performance categories.
Each MVP includes what is referred to as the foundational layer, which includes the Promoting
Interoperability measure/objective set and 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.
Promoting Interoperability performance category measures don’t need to be included in MVP
candidate submissions. The foundational layer measures are prefilled in the template because
they are required across all MVP candidates and can’t be changed. The Promoting
Interoperability performance category measure specifications are available on the Promoting
Interoperability Performance Category webpage.
Please complete and submit 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.
- 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.

2

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
to be considered for inclusion within an MVP.
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. The
following 2024 resources will be available on the QPP Resource Library:
• 2024 MIPS Quality Measures List (XLSX)
• 2024 Cross-Cutting Quality Measures (PDF)
• 2024 QCDR Measure Specifications (XLSX)
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. This MVP was developed to include an outcome
measure related to care provided by this single specialty.
o If an outcome measure isn’t 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. 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.
o Outcome-based administrative claims measures may be included to support the
quality performance category of an MVP candidate.
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.

3

In addition, MVPs should seek to identify/incorporate opportunities to promote diversity, equity,
and inclusion by selecting health equity focused improvement activities; there are 36 health
equity focused improvement activities in the current inventory. The 2024 Improvement Activity
Inventory will be available on the QPP Resource Library.
New improvement activities may be submitted using the 2024 Call for Measures and Activities
process, which will outlined on the QPP 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 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. The following cost
measure information will be available on the QPP Website:
• MIPS 2024 Summary of Cost Measures (PDF): Provides an overview of the cost
measures, their development, and estimated cost and clinician coverage metrics for the
measures currently in use.
• Measure Information Form (ZIP): Describes the methodology used to construct each
measure.
• Measure Codes List (ZIP): Contains service codes and clinical logic used in the
methodology, including episode triggers, exclusion categories, episode subgroups,
assigned items and services, and risk adjustors.
New cost measures may be submitted for consideration for use in the MIPS program using the
2024 Call for Measures and Activities process, which will be outlined on the QPP Resource
Library.
Submission and Review Process
On an annual basis, CMS intends to host a public MVP development webinar to review the MVP
development criteria as well as the timeline and process to submit a candidate MVP.
Candidate MVPs 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 2025
performance period/2027 MIPS payment year.
As MVP candidates are received, they will be reviewed 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.

4

In addition to the MVP development criteria, CMS will also evaluate the quality and cost
measures from a technical perspective to validate applicability to the clinician being measured
for performance. 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. Submitting an MVP candidate doesn’t 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.

Table 1: Instructions and Template

Please provide high-level information addressing the following 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

•
•

Primary/Alternative Contact
Names

•
•

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.

5

Intent of Measurement

•
•
•
•
•
•

•

Measure and Activity Linkages
with the MVP

•

•

•
Appropriateness

•

•
•
•

•

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 2.0 Framework
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 or are
they assessing the same clinical actions?).
Linkages between measures and activities should
be considered as complementary relationships.
Are the measures and activities related or a part of
the episode of care or continuum of care offered
by the clinicians?
Why are the chosen measures and activities most
meaningful to the specialty?
Is the MVP candidate developed for multiple
specialties or is it focused to a specific specialty? 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 care settings captured by the measures
represent those most appropriate for the specialty
intended by the MVP?
Prior to incorporating a measure in an MVP, is the
denominator of the measure inclusive of the
intended specialty or sub-specialty?

6

Comprehensibility

•
•

Incorporation of the Patient Voice

•
•

•

Is the MVP comprehensive and understandable by
the clinician or group?
Will the intent of the MVP be meaningful to
patients?
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?

7

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. 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 their availability within MIPS.
• For example, the 2023 Advancing Care for Heart Disease MVP includes 14 quality
measures and 11 improvement activities. Cardiac disease can encompass several
conditions relative to heart care; 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.
CMS isn’t 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 (Table 2B and Table 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.
Table 2A: Quality Measures, Improvement Activities, and Cost Measures
QUALITY MEASURES
IMPROVEMENT
COST MEASURES
ACTIVITIES
For each measure, provide:

For each activity, provide:

8

For each measure, provide:

QUALITY MEASURES

IMPROVEMENT
ACTIVITIES

COST MEASURES

9

Table 2B: Foundational Layer – Population Health Measures
QUALITY MEASURE TITLE
COLLECTION
MEASUR NQS DOMAIN
#
AND DESCRIPTION TYPE
E TYPE /
HIGH
PRIORITY

HEALTH
CARE
PRIORITY

MEASURE
STEWARD

479

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

Administrative
Claims

Outcome

Communication
and Care
Coordination

Promote
Effective
Communicatio
n&
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

10

Table 2C: Foundational Layer – Promoting Interoperability Measures
OBJECTIVE
MEASURE ID, TITLE, AND
REQUIRED EXCLUSION
DESCRIPTION
FOR
AVAILABLE
PROMOTIN
G
INTEROPE
RABILITY

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.

Yes

No

Annual requirement
for Promoting
Interoperability
submission but not
scored.

Protect Patient
Health
Information

PI_PPHI_2: High Priority Practices
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.

Yes

No

Annual requirement
for Promoting
Interoperability
submission but not
scored.

11

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTIN
G
INTEROPE
RABILITY

EXCLUSION
AVAILABLE

ADDITIONAL
INFORMATION

Attestation

PI_ONCDIR_1: ONC Direct Review
Attestation:
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.

Yes

No

Annual requirement
for Promoting
Interoperability
submission but not
scored.

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.

Yes

No

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 transmitted
electronically using CEHRT.

Yes

Yes

12

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTIN
G
INTEROPE
RABILITY

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.

Yes

Yes

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).

Yes

No

13

EXCLUSION
AVAILABLE

ADDITIONAL
INFORMATION

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTIN
G
INTEROPE
RABILITY

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.

14

EXCLUSION
AVAILABLE

ADDITIONAL
INFORMATION

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTIN
G
INTEROPE
RABILITY

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.

15

Yes

EXCLUSION
AVAILABLE

No

ADDITIONAL
INFORMATION

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

REQUIRED
FOR
PROMOTIN
G
INTEROPE
RABILITY

Health
Information
Exchange

PI_HIE_6: Enabling Exchange
Under the Trusted Exchange
Framework and Common
Agreement (TEFCA):
The MIPS eligible clinician or group
must attest to the following:
• Participating as a signatory
to a Framework Agreement
(as that term is defined by
the Common Agreement for
Nationwide Health
Information Interoperability
as published in the Federal
Register and on ONC’s
website) in good standing
(that is, not suspended) and
enabling secure, bidirectional exchange of
information to occur, in
production, for every patient
encounter, transition or
referral, and record stored
or maintained in the EHR
during the performance
period, in accordance with
applicable law and policy.
• Using the functions of
CEHRT to support bidirectional exchange of
patient information, in
production, under this
Framework Agreement.

16

Yes

EXCLUSION
AVAILABLE

No

ADDITIONAL
INFORMATION

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.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTIN
G
INTEROPE
RABILITY

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.

17

EXCLUSION
AVAILABLE

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 they are relatable in
clinical topic, setting, and specialty (including nurse practitioners, physician assistants,
certified registered nurse anesthetists, and clinical social workers) to the cost measure(s)
and activities within the MVP?
- These quality measures should include appropriate settings and applicability to nonphysician practitioners (e.g., nurse practitioners, physician assistants, etc.).
• 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.
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)?

18

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?

Version History
Date

Comments

09/29/2023

Original version

###
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381314 (Expiration date: 01/31/2025). The time required to complete this information collection is estimated to average
2 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do
not send applications, claims, payments, medical records or any documents containing sensitive information to the
PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or
retained. If you have questions or concerns regarding where to submit your documents, please contact QPP at
qpp@cms.hhs.gov.

19