MIPS Quality Measures Overview

MIPS participants must submit data for at least six quality measures—one of which must be an outcome measure. Below, you’ll find information about the available quality measures in the WebPT EMR.

Note: SLPs are only required to submit the four measures that have been made available in their specialty set.

Available Measures

This table also includes whether the measure is topped out, high priority, and/or has historical benchmark data, as these items impact overall scoring ability. Click here to learn more about how measures are scored.

*The FOTO Outcomes Measures approved for PTs and OTs require a special process for inclusion in WebPT MIPS reporting. Please see the FOTO Reporting section below.

1 Topped Out: A measure becomes “topped out” if the median performance rate is 95% or higher (non-inverse measures). These measures have also been given a max of 7 points as long as the submission meets all other requirements (instead of the typical 10 points). Topped out measures are still available for bonus points.

2 High Priority: High priority process measures are available for one bonus point for each high priority process measure reported—after the first high priority process measure reported. High priority outcomes measures (FOTO only) are available for two bonus points—for each additional measure reported—beyond the first high priority outcome reported.

3 Benchmark: Measures without a benchmark are capped at 3 points. Because these measures don’t have enough data (yet) to create a benchmark, participants cannot receive a performance rate for reporting these measures. You’ll receive points for simply completing the measure and contributing to the benchmarking data.

MIPS Measures Links

Each measure document below contains information on who can report the measure, measure reporting requirements, and how to report the measure in the WebPT EMR. Select a measure to learn more.

• #126: Diabetic Foot and Ankle Care, Peripheral Neuropathy
  • SOAP 2.0 #126: Diabetic Foot and Ankle Care, Peripheral Neuropathy
• #127: Diabetic Foot and Ankle Care, Ulcer Prevention--Evaluation of Footwear
  • SOAP 2.0 #127 Diabetic Foot and Ankle Care, Ulcer Prevention--Evaluation of Footwear
• #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • SOAP 2.0 #128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
• #130: Documentation and Verification of Current Medications in the Medical Record  
  • SOAP 2.0 #130 Documentation and Verification of Current Medications in the Medical Record
• #134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
  • SOAP 2.0 #134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up
• #154: Falls: Risk Assessment
  • SOAP 2.0 #154 Falls: Risk Assessment
• #155: Falls: Plan of Care
  • SOAP 2.0 #155 Falls: Plan of Care
• #181: Elder Maltreatment Screen and Follow-Up Plan
  • SOAP 2.0 #181 Elder Maltreatment Screen and Follow-Up Plan
• #182: Functional Outcome Assessment
  • SOAP 2.0 #182 Functional Outcome Assessment
• #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
• #HM4: Functional Status Change for Patients with Upper-limb Functional Status Deficit
• #HM5: Functional Status Change for Patients with Neck Functional Status Deficit
• #HM6: Functional Status Change for Patients with Low Back Functional Status Deficit
• #HM7: Functional Status Change for Patients with Vestibular Dysfunction
• #HM8: Functional Status Change for Patients with Lower Extremity Functional Status Deficit

Reporting FOTO Measures

We can only support limited documentation of the FOTO measures because they are proprietary to FOTO. Therefore, the way you report on these measures is different than the other measures listed above. We are actively working on improving this reporting process.

For complete instructions, click here.