1. (a) For a MIPS payment year, CMS uses the following quality measures, as applicable, to assess performance in the quality performance category:

   1. (1) Measures included in the MIPS final list of quality measures established by CMS through rulemaking;
   2. (2) QCDR measures approved by CMS under § 414.1400;
   3. (3) Facility-based measures described in § 414.1380; and
   4. (4) MIPS APM measures described in § 414.1370.

2. (b) Unless a different scoring weight is assigned by CMS, performance in the quality performance category comprises:

   1. (1) 60 percent of a MIPS eligible clinician's final score for MIPS payment year 2019.
   2. (2) 50 percent of a MIPS eligible clinician's final score for MIPS payment year 2020.
   3. (3) 45 percent of a MIPS eligible clinician's final score for MIPS payment years 2021 and 2022.
   4. (4) 40 percent of a MIPS eligible clinician's final score for the MIPS payment year 2023.
   5. (5) 30 percent of a MIPS eligible clinician's final score for the MIPS payment year 2024 and future years.

3. (c)

   1. (1) CMS uses the following criteria to determine the removal of a quality measure:

      1. (i) If the Secretary determines that the quality measure is no longer meaningful, such as measures that are topped out.
      2. (ii) If a measure steward is no longer able to maintain the quality measure.
      3. (iii) If the quality measure reached extremely topped out status.
      4. (iv) If the quality measure does not meet case minimum and reporting volumes required for benchmarking after being in the program for 2 consecutive CY performance periods.
      5. (v) If the quality measure is duplicative.
      6. (vi) If the quality measure is not updated to reflect current clinical guidelines, which are not reflective of a clinician's scope of practice.
      7. (vii) If the quality measure is a process measure.
      8. (viii) If the quality measure addresses a measurement gap.
      9. (ix) If the quality measure is a patient-reported outcome.
      10. (x) If the quality measure is not available for MIPS quality reporting by or on behalf of all MIPS eligible clinicians.
      11. (xi) The robustness of the quality measure.
      12. (xii) Consideration of the quality measure in developing MIPS Value Pathways (MVPs).

   2. (2) A quality measure that otherwise meets the criteria for removal in paragraph (c)(1) of this section may nonetheless be retained based on the following considerations:

      1. (i) Whether the removal of the process measure impacts the number of measures available for a specific specialty.
      2. (ii) Whether the quality measure addresses a priority area.
      3. (iii) Whether the quality measure promotes positive outcomes in patients.
      4. (iv) Whether the quality measure is designated as high priority or not.
      5. (v) Whether the quality measure has reached extremely topped out status.
      6. (vi) Evaluation of the quality measure's performance data.

[83 FR 60078, Nov. 23, 2018, as amended at 84 FR 63195, Nov. 15, 2019; 85 FR 85031, Dec. 28, 2020; 89 FR 98561, Dec. 9, 2024]