Crosswalk: Appendix J1

MVP Development Standardized Template
CY 2023 Final versus CY 2024 Final
Burden impact: The changes to the MVP Development Standardized Template reflect annual
language updates, as there were no policy changes that impacted this document from the CY
2023 Physician Fee Schedule (PFS) Final Rule for the Quality Payment Program to the CY
2024 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 2023 Final Rule text:
Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions And
Template
CY 2024 Final Rule text:
Submitting MIPS Value Pathways (MVP) Candidates: Instructions and Template
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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.
CY 2024 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 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.
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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.

CY 2024 Final Rule text:

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.
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.
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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.

CY 2024 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
to be considered for inclusion within an MVP.
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Quality Measures
The current inventory of MIPS quality measures and Quality Clinical Data Registry (QCDR)
measures include both cross-cutting and specialty/clinical topic specific quality measures.
Please view the current MIPS quality measures, 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.

CY 2024 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. 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.
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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 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.
CY 2024 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 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.
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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.
CY 2024 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 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.
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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.

CY 2024 Final Rule text:
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.
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.
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TABLE 1: MVP DESCRIPTIVE INFORMATION
MVP Name

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

Primary/Alternative Contact
Names

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

Intent of Measurement

• What is the intent of the MVP?
• Is the intent of the MVP the same at the individual
clinician and group level?
• Are there opportunities to improve the quality of care
and value in the area being measured?
• Why is the topic of measurement meaningful to
clinicians?
• Does the MVP act as a vehicle to incrementally
phase clinicians into APMs? How so?
• Is the MVP reportable by small and rural practices?
Does the MVP consider reporting burden to those
small and rural practices?
• Which Meaningful Measure Domain(s) does the
MVP address?

Measure and Activity Linkages
with the MVP

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

Appropriateness

• Is the MVP 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?

Comprehensibility

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

Incorporation of the Patient Voice

• Does the MVP take into consideration the patient
voice? How?
• Does the MVP take into consideration patients in
rural and underserved areas?
• 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?

CY 2024 Final Rule text:

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

•
•

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 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?

Appropriateness

•

•
•
•

•

Comprehensibility

•
•

Incorporation of the Patient Voice

•
•

•

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?
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?

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Table 2a: Instructions and Template

Please use the Table 2a template format below to identify the quality measures, improvement
activities, and cost measures for your MVP candidate. Specifically, at a minimum, Table 2a
should include measure/activity IDs, measure/activity titles, measure collection types, and
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.
CY 2024 Final Rule text:
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.
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CY 2023 Final Rule text
Table 2A: Quality Measures, Improvement Activities, and Cost Measures
QUALITY MEASURES
IMPROVEMENT
COST MEASURES
ACTIVITIES
For each measure, provide:

For each activity, provide:

For each measure, provide:

CY 2024 Final Rule text
Table 2A: Quality Measures, Improvement Activities, and Cost Measures
QUALITY MEASURES
IMPROVEMENT
COST MEASURES
ACTIVITIES
For each measure, provide:

For each activity, provide:

For each measure, provide:

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CY 2023 Final Rule text
Table 2B: Foundational Layer – Population Health Measures
QUALITY
#

MEASURE TITLE
AND DESCRIPTION

COLLECTION
TYPE

MEASURE
TYPE /
HIGH
PRIORITY

NQS DOMAIN

HEALTH
CARE
PRIORITY

MEASURE
STEWARD

479

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

Administrative
Claims

Outcome

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

CY 2024 Final Rule text
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

*****
Change #13:
Location: Pages 11-17
Reason for Change:
Language and punctuation updates, updated measure titles and descriptions as applicable
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.

CY 2024 Final Rule text
Table 2C: Foundational Layer – Promoting Interoperability Measures
OBJECTIVE
MEASURE ID, TITLE, AND
REQUIRED
EXCLUSION
DESCRIPTION
FOR
AVAILABLE
PROMOTING
INTEROPER
ABILITY

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.

OBJECTIVE

Attestation

Attestation

e-Prescribing

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTING
INTEROPER
ABILITY

EXCLUSION
AVAILABLE

ADDITIONAL
INFORMATION

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.
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.

Yes

No

Annual requirement
for Promoting
Interoperability
submission but not
scored.

PI_EP_1: e-Prescribing:
At least one permissible
prescription written by the MIPS
eligible clinician is transmitted
electronically using CEHRT.

Yes

Yes

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTING
INTEROPER
ABILITY

EXCLUSION
AVAILABLE

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
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).

Yes

No

ADDITIONAL
INFORMATION

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

REQUIRED
FOR
PROMOTING
INTEROPER
ABILITY

EXCLUSION
AVAILABLE

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.

OBJECTIVE

MEASURE ID, TITLE, AND
DESCRIPTION

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.

REQUIRED
FOR
PROMOTING
INTEROPER
ABILITY

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

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.

REQUIRED
FOR
PROMOTING
INTEROPER
ABILITY

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
PROMOTING
INTEROPER
ABILITY

EXCLUSION
AVAILABLE

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.

*****
Change #14:
Location: Page 18
Reason for Change:
Language updates
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.
CY 2024 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 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?
o 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.