CY 2025 Quality Payment Program and Medicare Shared Savings Program Summary

Recently, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) proposed rule for CY 2025 (CMS-1807-P). Updates and programmatic changes to the Quality Payment Program (QPP) and the Medicare Shared Savings Program (MSSP) are also discussed with the MPFS rule. This summary is specific to the QPP and MSSP. With the release of the rule CMS provides a fact sheet for the QPP, and a fact sheet for the MSSP. Comments are due September 9.

The page numbers listed in this document refer to the display copy of the proposed rule.

Medicare Shared Savings Program – p. 667

Highlight: CMS proposes to establish new prepaid shared savings for eligible ACOs and modify the MSSP’s financial and beneficiary assignment methodologies.

The Medicare Shared Savings Program (MSSP) allows eligible healthcare providers, such as physicians, hospitals, and others, to form or join an accountable care organization (ACO). By doing so, they agree to take responsibility for the overall cost and quality of care provided to a specific group of Medicare fee-for-service (FFS) beneficiaries. Providers and suppliers who participate in an ACO still receive traditional Medicare FFS payments under Parts A and B. If an ACO meets certain quality and savings criteria, it may receive shared savings payments. In some cases, it may also be required to share in losses if healthcare spending increases.

CMS proposes to establish a new “prepaid shared savings” to assist eligible ACOs with a history of earning shared savings with cash flow and to encourage investments to improve patient care and services through care coordination or healthcare infrastructure. Eligible ACOs include those participating in Levels C-E of the BASIC track or the ENHANCED track. Payments would be provided quarterly. At least 50% of prepaid shared savings would be required to be spent on direct beneficiary services and up to 50% of the remaining shared savings can be spent on staffing and healthcare infrastructure.

CMS proposes changes to the MSSP beneficiary assignment methodology, to revise the definition of primary care services. Specifically, the proposed additions to the MSSP definition of primary care services include the following: Safety Planning Interventions; Post-Discharge Telephonic Follow-up Contacts Intervention; Virtual Check-in Service; Advanced Primary Care Management Services; Cardiovascular Risk Assessment and Risk Management; Interprofessional Consultation; Direct Care Caregiver Training Services; and Individual Behavior Management/Modification Caregiver Training Services. CMS also proposes to broaden the existing exception to the program’s voluntary alignment policy to apply to beneficiaries that are claims-based and assigned to entities participating in certain disease- or condition-specific CMS Innovation Center ACO models.

Through the Quality Payment Program (QPP), CMS proposes to create an APM Performance Pathway (APP) Plus quality measure set that aligns with the Adult Universal Foundation quality measures. To align quality measure reporting across CMS’ quality programs, CMS proposes modifications to the MSSP to require ACOs to report the APP Plus quality measure set.

Request for Information: Building upon the MIPS Value Pathways (MVPs) Framework to Improve Ambulatory Specialty Care – p. 1,105

Highlights: CMS seeks input regarding the design of a future ambulatory specialty model. Responses will inform potential future rulemaking and other policy development.

CMS recognizes that primary care teams coordinate with specialists more now than ever before, and this coordination is critical to the ongoing management of chronic conditions. CMS is considering a model design that would increase the engagement of specialists in value-based payment and encourage specialty care provider engagement with primary care providers and beneficiaries.

Specifically, CMS is exploring development of a model for specialists in ambulatory settings that would leverage the Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) framework. As currently envisioned, instead of receiving a MIPS payment adjustment, participants would receive a payment adjustment based on performance on clinically relevant MVP measures compared to other model participants of their same specialty type and clinical profile.

Currently, under MIPS, performance and payment adjustments are based on a range of measures reported by clinicians. A clinician’s performance is assessed against a pool of all clinicians, regardless of specialty type or the services they provide. An ambulatory specialty model would provide for a more targeted approach, evaluating clinicians on relevant measures and comparing them to clinicians in the same specialty. This approach aims to produce scores and subsequent payment adjustments that are more reflective of clinician performance, offering insights into care coordination's impact on patient outcomes and incentivizing better care.

According to CMS, using the MVP framework as a foundation for a model advances value-based care by narrowing the measure set based on clinician specialty, medical condition, or patient population, allowing for meaningful comparisons and relevant feedback, thus strengthening accountability in specialty care. Additionally, the model's payment methodology could address concerns about the MIPS program by testing enhanced incentives to encourage meaningful specialty care transformation and increased integration between primary and specialty care. CMS also believes that this model could reach a broad range of clinicians of various specialty types that have limited opportunity to participate in Advanced APMs

CMS did not propose a mandatory specialty model in the proposed rule. Instead, CMS seeks comments on the potential model, including considering mandatory participation of relevant specialty care providers to overcome challenge such as selection bias and participant attrition, and to ensure the model is reaching a representative group of providers and beneficiaries to facilitate scaling of the model test.

Beginning on page 1,111 of the proposed rule, CMS proposes thirty-seven questions for stakeholder feedback. Specifically, CMS seeks feedback on the following topics related to the design of a future ambulatory specialty model: (1) Participant definition; (2) MVP performance assessment; (3) Payment methodology; (4) Care delivery and incentives for partnerships with accountable care entities and integration with primary care; (5) Health information technology and data sharing; (6) Health equity; and (7) Multi-payer alignment.

Updates to the Quality Payment Program – p. 1,175

Highlight: CMS proposes six new MVPs and issued a request for information on MVP development and clinician readiness. CMS proposes updates to the MIPS measure/activity inventories and scoring methodologies while maintaining the current performance threshold and data completeness criteria.

Authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program is a value-based payment program, by which the Medicare program rewards clinicians who provide high-value, high quality care to their patients in a cost-efficient manner. There are two ways for clinicians to participate in the Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

For the MIPS participation track, MIPS eligible clinicians are subject to a MIPS payment adjustment (positive, negative, or neutral) based on their performance in four performance categories: cost, quality, improvement activities, and Promoting Interoperability. For CY 2025 performance period/2027 MIPS payment year, the scoring weights are unchanged and remain as follows: 30 percent for the quality performance category; 30 percent for the cost performance category; 15 percent for the improvement activities performance category; and 25 percent for the Promoting Interoperability performance category.

For the Advanced APM track, if an eligible clinician participates in an Advanced APM and achieves Qualifying APM Participant (QP) or Partial QP status, they are excluded from the MIPS reporting requirements and payment adjustment. Eligible clinicians who are QPs for the CY 2024 performance year receive a 1.88 percent APM Incentive Payment in the 2026 payment year. Beginning with the CY 2024 performance year (payment year 2026), QPs will also receive a higher PFS payment rate (calculated using the differentially higher “qualifying APM conversion factor”) than non-QPs.

Transforming the QPP – p. 1,177

There are currently three MIPS reporting options available for physician participation: Traditional MIPS; MIPS Value Pathways (MVPs); and Alternative Payment Model (APM) Performance Pathway (APP). CMS is continuing to develop new MVPs to allow for a more cohesive participation experience by connecting activities and measures from the four MIPS performance categories that are relevant to a specialty, medical condition, or a particular population. In this proposed rule, CMS clarified its intent to move to full MVP adoption and to sunset traditional MIPS in the future. CMS does not propose a target year to sunset traditional MIPS; however, the agency seeks feedback on clinician readiness for MVP reporting and MIPS policies needed to sunset traditional MIPS in the CY 2029 performance period/2031 MIPS payment year. CMS’ goal is to have sufficient MVPs to meet the goals of the MVP Framework, allow reporting by all clinicians in MIPS, sunset traditional MIPS, and transition fully to MVPs.

MVP Development and Maintenance – p. 1,179

For CY 2025, CMS proposes six new MVPs focused including Optimal Care for Patients with Urologic Conditions. Based on an analysis of internal data, the addition of the six new MVPs would allow approximately 80 percent of specialties participating in the program to submit applicable MVPs. CMS also proposes to update MVP maintenance procedures and MVP scoring.

The role of MVPs in Transforming MIPS – p. 1,190

Voluntary reporting of MVPs started in the CY 2023 performance period/2025 MIPS payment year. Based on a CMS review of internal data, over 750 groups and clinicians registered to report MVPs for the CY 2023 performance period/2025 MIPS payment year. As CMS supports a gradual movement to MVPs, the agency is interested in learning from early MVP participants to understand lessons learned and barriers encountered or overcome to enable MVP submission.

While CMS has made progress in developing MVPs for specialties and priority clinical conditions, the agency is considering alternative approaches to developing additional MVPs to ensure that all MIPS eligible clinicians have MVPs to report. Specifically, CMS seeks comment on approaches that include expanding finalized MVPs to include more specialties or subspecialties related to a care condition; developing new, broader MVPs with a different emphasis from current MVPs focused on a single specialty or clinical condition; and developing MVPs for non-patient facing MIPS eligible clinicians. CMS provides more detail on these approaches on page 1196 of the proposed rule.

Additionally, CMS is interested in understanding clinician readiness to report MVPs with the eventual sunset of traditional MIPS and ensuring applicable MVPs are available for all clinicians. CMS is also interested in refining group and subgroup composition criteria, including specific considerations for multispecialty small practices. CMS invites the public to provide feedback to the questions on page 1,206 of the proposed rule.

APM Performance Pathway (APP) – p. 1180

CMS proposes to create an APM Performance Pathway (APP) Plus quality measure set within the APP, beginning with the CY 2025 performance period/2027 MIPS payment year. CMS did not propose changes to the existing APP quality measure set. Instead, the agency proposes to create the APP Plus quality measure set, which would include the six measures currently in the APP quality measure set and incrementally incorporate the remaining five Adult Universal Foundation quality measures for a total of eleven measures in the APP Plus quality measure set from the CY 2025 through the CY 2028 performance period. MIPS eligible clinicians, groups, or APM Entities reporting the APP can choose to report either the APP or APP Plus quality measure set. CMS also proposes that Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) will be required to report the APP Plus quality measure set.

MIPS Performance Category Measures and Activities – p. 1,182

• Quality: CMS proposes to establish data submission criteria for the MIPS APP Plus measure set; maintain the MIPS data completeness criteria threshold to at least 75 percent for the CY 2027 and CY 2028 performance periods; and establish a measure set inventory of 196 MIPS quality measures.
• Cost: CMS proposes six new episode-based cost measures and revisions to two existing episode-based cost measures.
• Improvement activities: CMS proposes to add two new, modify two existing, and remove eight existing improvement activities.
• Promoting interoperability: CMS did not propose any changes to activities in this MIPS category.

Proposes Minimum Criteria for a Qualifying Data Submission for the MIPS Quality, Improvement Activities, and Promoting Interoperability Performance Categories – p. 1,245

• Quality Performance Category: CMS proposes to specify that to be considered, a data submission must include numerator and denominator data for at least one MIPS quality measure from the final list of MIPS quality measures.
• Improvement Activities Performance Category: CMS proposes to specify data submission for clinicians. The agency will score a data submission only if the submission includes a response of “yes” for at least one improvement activity included in the improvement activities inventory for the MIPS performance period.
• Promoting Interoperability Performance Category: CMS proposes that the minimum criteria for a qualifying data submission for the Promoting Interoperability performance category must include all required reporting elements for the performance category. Specifically, the minimum criteria as a qualifying data submission for the Promoting Interoperability performance category must include all the following elements: Performance data; required attestation statements; CMS EHR Certification ID (CEHRT ID) from the Certified Health IT Product List (CHPL); and the start date and end date for the applicable performance period.

Treatment of Multiple Data Submissions – p. 1,258

CMS proposes to amend its policy for multiple data submissions for the quality, improvement activities, and promoting interoperability performance categories. Specifically, for multiple data submissions received, CMS proposes to calculate a score for each data submission received and assign the highest of the scores.

MIPS Performance Category Measures and Activities – p. 1,262

Data Submission Criteria – p. 1,264

CMS proposes to require that all measures within the APP Plus quality measure set be reported, and all measures in the APP Plus quality measure set be scored, unless a measure does not have a benchmark or meet the case minimum requirements. CMS seeks public comment on the proposal to establish the data submission criteria for the APP Plus quality measure set, specifically the proposal to require the reporting of all measures within the APP Plus quality measure set.

Data Completeness Criteria – p. 1,267

The data completeness criteria threshold requires that MIPS eligible clinicians, groups, virtual groups, or APM Entities submit data on a minimum percentage of their patients, depending on the measure and patient type, regardless of payer, to meet the specified performance period requirements. CMS proposes to maintain the data completeness criteria threshold of at least 75 percent for two additional years.

Inventory of Quality Measures – p. 1,276

For the CY 2025 performance period, CMS proposes an inventory of 196 MIPS quality measures. The rule proposes the following changes to the quality performance category measure inventory:

• Implementation of nine new MIPS quality measures;
  • Five high priority measures, of which two are also patient-reported outcome measures
• Removal of 11 MIPS quality measures; and
  • 2 MIPS quality measure are duplicative to a proposes new quality measure; 3 MIPS quality measures are duplicative to current quality measures; 1 MIPS quality measure has reached the topped-out lifecycle; 2 MIPS quality measures are extremely topped out; 1 MIPS quality measure is no longer owned/maintained; and 2 MIPS quality measures have limited adoption and consequently, have not been able to establish benchmarks to provide a meaningful impact to quality improvement; and
• Substantive changes to 66 MIPS quality measures.

See Appendix A for the proposed modifications to the MIPS quality measure inventory relevant to urology for the CY 2025 performance period.

Quality Performance Category Requests for Information – p. 1,281

Survey Modes for the Administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey – p. 1,283

CMS seeks feedback on the potential expansion of the survey methods of the CAHPS for MIPS Survey. The current procedure is to administer the survey first through the mail and then by phone interview with nonrespondents. The proposed expansion would include an initial administration of the survey by web, followed by mail, and then by phone. Based on results from a field test, CMS believes that the web-mail-phone protocol will result in a higher response rate than the mail-phone protocol.

Guiding Principles for Patient-Reported Outcome Measures in Federal Models, and Quality Reporting and Payment Programs Request for Information – p. 1,284

CMS aims to elevate the patient voice by incorporating Patient-Reported Outcome Measures (PROMs) and Patient-Reported Outcome Performance Measures (PRO–PMs) in CMS quality reporting and payment programs and CMMI models. As CMS works to include more PROMs and PRO-PMs in CMS quality reporting and payment programs and CMMI models, the agency plans to develop a set of guiding principles and considerations for the selection and implementation of PROMs or PRO-PMs. CMS seeks feedback from the public on principles related to data infrastructure, selection, feasible implementation, and patient engagement of PROMs and PRO-PMs.

Optimal Care for Patients with Urologic Conditions MVP – p. 2,193

Recently, the AUA submitted an MVP for approval and implementation within the Medicare program. The proposed Optimal Care for Patients with Urologic Conditions MVP focuses on assessing optimal care for patients treated for a broad range of urologic conditions, including kidney stones, urinary incontinence, bladder cancer, and prostate cancer. This MVP would be most applicable to clinicians who treat patients within the practice of urology including general urologists, urology oncologists, and sub-specialists focused on urology care for women, including nonphysician practitioners (NPPs) such as nurse practitioners and physician assistants.

Quality Measures

CMS proposes to include nine MIPS quality measures and five QCDR measures within the quality performance category of this MVP, which are specific to the clinical topic of urology. CMS reviewed the MIPS quality measure inventory and considered feedback received during the 2025 MVP candidate feedback period to determine which quality measures best represent the clinical topic of this MVP.

The following quality measures provide a meaningful and comprehensive assessment of the clinical care for clinicians who specialize in urology:

• Q050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older: This MIPS quality measure ensures patients have a documented plan of care for urinary incontinence at least once within 12 months.
• Q462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy: This MIPS quality measure ensures patients with prostate cancer currently on or starting androgen deprivation therapy (ADT), with an intent for treatment greater than or equal to 12 months, have a bone density evaluation prior to starting or within 3 months after the start of ADT.
• Q476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia: This MIPS quality measure assesses for improvement in urinary symptoms for patients with a diagnosis of benign prostatic hyperplasia based upon the International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI).
• Q481: Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer: This MIPS quality measure ensures patients initially diagnosed with non-muscle invasive bladder cancer have treatment initiated within 6 months of the cancer staging.
• AQUA8: Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy: This QCDR measure assesses the number of patients who have urinary retention, infection, or a new antibiotic prescription at least 24 hours after and within 30 days of a prostate biopsy or inpatient consultation or require hospitalization within 30 days of prostate biopsy.
• AQUA14: Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment: This QCDR measure assesses the number of patients who had a repeat shock wave lithotripsy procedure within the 6 months of the initial treatment.
• AQUA15: Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures: This QCDR measure ensures patients have a urinalysis or culture within 14 days prior to surgical stone procedures.
• AQUA16: Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease: This QCDR measure assesses the number of patients who undergo a second TURBT within 6 weeks of the initial procedure.
• MUSIC4: Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low-Risk Prostate Cancer Patients: This QCDR measure ensures newly diagnosed low-risk prostate cancer patients are managed via active surveillance or watchful waiting to maintain the patient’s quality of life.

The following universally applicable MIPS quality measures are relevant to clinicians who specialize in urology. The measures assess for age-specific screenings, and follow-up actions for select measures, in addition to recommended vaccinations:

• Q318: Falls: Screening for Future Fall Risk: This MIPS quality measure ensures patients are screened each performance period for future fall risk.
• Q321: CAHPS for MIPS Clinician/Group Survey: This survey provides direct input from patients and their experience regarding timely care, effective communication, shared decision making, care coordination, promotion of health and education, completion of health status/functionality, and courtesy of office staff.
• Q358: Patient-Centered Surgical Risk Assessment and Communication: This MIPS quality measure ensures a personalized surgical risk assessment is completed on each patient using a validated risk calculator or multi-institutional clinical data prior to the surgery along with discussion of the identified risks with the surgeon.
• Q487: Screening for Social Drivers of Health: This MIPS quality measure ensures adults are screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.
• Q503: Gains in Patient Activation Measure (PAM®) Scores at 12 Months: This MIPS quality measure ensures capture of the patient voice and experience of care related to the patient’s understanding and confidence in the clinician’s ability to manage their health and be an active partner in the health care journey.

Improvement Activities

CMS reviewed the Improvement Activities Inventory and considered feedback received during the 2025 MVP candidate feedback period to determine the set of improvement activities to include in this MVP. CMS proposes to include seventeen improvement activities that reflect actions and processes undertaken by clinicians who specialize in urology, as well as activities that promote patient engagement and patient-centeredness, health equity, shared decision making, and care coordination. These improvement activities provide opportunities for clinicians, in collaboration with patients, to drive outcomes and improve quality of care. The following improvement activities are proposed for inclusion in this MVP:

• IA_AHE_3: Promote Use of Patient-Reported Outcome Tools
• IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
• IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings
• IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care
• IA_CC_7: Regular training in care coordination
• IA_CC_13: Practice improvements to align with OpenNotes principles
• IA_CC_17: Patient Navigator Program
• IA_EPA_2: Use of telehealth services that expand practice access
• IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff
• IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
• IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
• IA_PM_17: Participation in Population Health Research
• IA_PM_21: Advance Care Planning
• IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
• IA_PSPA_12: Participation in private payer CPIA
• IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvement processes
• IA_PSPA_21: Implementation of fall screening and assessment programs

Cost Measures

CMS proposes to include three MIPS cost measures within the cost performance category of this MVP, which apply to the clinical topic of urology. CMS reviewed the MIPS cost measure inventory and considered feedback received during the 2025 MVP candidate feedback period to determine the set of cost measures to include in this MVP. The following cost measures provide a meaningful assessment of the clinical care for clinicians who specialize in urology and align with other measures and activities within this MVP:

• Medicare Spending Per Beneficiary (MSPB) Clinician: This MIPS cost measure applies to clinicians providing care in inpatient hospitals, including those who treat patients with urology-related conditions or procedures.
• Renal or Ureteral Stone Surgical Treatment: This MIPS episode-based cost measure assesses costs associated with surgical treatment for renal or ureteral stones. This also aligns with quality measures such as AQUA14: Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment or AQUA15: Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures.
• Prostate Cancer: The proposed MIPS episode-based cost measure would assess costs associated with prostate cancer. This also aligns with quality measures such as Q462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy or MUSIC4: Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low-Risk Prostate Cancer Patients.

Optimal Care for Patients with Urologic Conditions MVP Tables

CMS considered measures and improvement activities available within the MIPS inventory and selected those determined best fit the clinical concept of the proposes Optimal Care for Patients with Urologic Conditions MVP. CMS requests comments on the measures and activities included in this MVP.

Symbol Key:

Carat symbol (^): new proposes measures and improvement activities

Single asterisk (*): existing measures and improvement activities with proposes revisions

Double asterisk (**): measures and improvement activities only available when included in an MVP

Single exclamation point (!): high priority measures

Double exclamation point (!!): outcome measures

Tilde (~): measures and improvement activities that include a health equity component

Percent (%): attestation to IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation provides full credit for the improvement activity performance category

 

TABLE A.4a: Optimal Care for Patients with Urologic Conditions MVP Measures and Improvement Activities – p. 2195

Quality	Improvement Activities	Cost
(!) Q050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older (Collection Type: MIPS CQMs Specifications)   (!) Q318: Falls: Screening for Future Fall Risk (Collection Type: eCQM Specifications)   (!) Q321: CAHPS for MIPS Clinician/Group Survey (Collection Type: CSV)   (!) Q358: Patient-Centered Surgical Risk Assessment and Communication (Collection Type: MIPS CQMs Specifications)   (*) Q462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (Collection Type: eCQM Specifications)   (!!) Q476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia (Collection Type: eCQM Specifications)   (!) Q481: Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer (Collection Type: eCQM Specifications)   (~)(!) Q487: Screening for Social Drivers of Health (Collection Type: MIPS CQMs Specifications)   (*)(!!) Q503: Gains in Patient Activation Measure (PAM®) Scores at 12 Months (Collection Type: MIPS CQMs Specifications)   (!!) AQUA8: Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy (Collection Type: QCDR)   (!!) AQUA14: Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment (Collection Type: QCDR)   (!) AQUA15: Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures (Collection Type: QCDR)   AQUA16: Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease (Collection Type: QCDR)   (!) MUSIC4: Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low-Risk Prostate Cancer Patients (Collection Type: QCDR)	(~) IA_AHE_3: Promote use of Patient-Reported Outcome Tools (High)   (~) IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health (High)   IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings (High)   IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care (Medium)   IA_CC_7: Regular training in care coordination (Medium)   IA_CC_13: Practice improvements to align with OpenNotes principles (Medium)   IA_CC_17: Patient Navigator Program (High)   IA_EPA_2: Use of telehealth services that expand practice access (Medium)   (*) IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff (Medium)   (**) IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways (High)   (%) IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation   IA_PM_17: Participation in Population Health Research (Medium)   IA_PM_21: Advance Care Planning (Medium)   (~) IA_PSPA_7: Use of QCDR data for ongoing practice assessment and Improvements (Medium)   IA_PSPA_12: Participation in private payer CPIA (Medium)   IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvement Processes (Medium)   IA_PSPA_21: Implementation of fall screening and assessment programs (Medium)	Renal or Ureteral Stone Surgical Treatment   Medicare Spending Per Beneficiary (MSPB) Clinician   (^) Prostate Cancer

 

TABLE A.4b: Optimal Care for Patients with Urologic Conditions MVP Foundational Layer – p. 2197

Population Health Measures

Promoting Interoperability

(!!) Q479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Systems (MIPS) Groups (Collection Type: Administrative Claims)   (!!) Q484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Collection Type: Administrative Claims)

Security Risk Analysis   High Priority Practices Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)   e-Prescribing   Query of Prescription Drug Monitoring Program (PDMP)   Provide Patients Electronic Access to Their Health Information   Support Electronic Referral Loops by Sending Health Information AND Support Electronic Referral Loops by Receiving and Reconciling Health Information OR Health Information Exchange (HIE) Bi-Directional Exchange OR Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)   Immunization Registry Reporting   Syndromic Surveillance Reporting (Optional)   Electronic Case Reporting   Public Health Registry Reporting (Optional)   Clinical Data Registry Reporting (Optional)   Actions to Limit or Restrict Compatibility or Interoperability of CEHRT   ONC Direct Review Attestation

 

Appendix A

New Specialty Measure Sets Proposed for Addition and Modifications to Previously Finalized Specialty Measure Sets Proposed for the CY 2025 Performance Period/2027 MIPS Payment Year and Future Years – p. 1,856

Measures Proposed for Addition to the Urology Specialty Set
Measure Type	Measure Title and Description	Measure Steward
Process	Adult COVID-19 Vaccination Status: Percentage of patients aged 18 years and older seen for a visit during the performance period that are up to date on their COVID-19 vaccinations as defined by CDC recommendations on current vaccination.	Centers for Medicare & Medicaid Services

 

Previously Finalized Measures Proposed for Removal from the Urology Specialty Set
Measure Type	Measure Title and Description	Measure Steward
Process	Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High-Risk Prostate Cancer: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate.	American Urological Association Education and Research
Outcome	Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.	American Urogynecologic Society