June 2017 – Vol. 36, No. 5

What Can I Submit for Each Category in 2017?

This resource provides a non-exhaustive sample of measures for quality, advancing care information, and improvement activities that may apply to otolaryngologist—head and neck surgeons reporting under the partial or full reporting period. For more information on reporting period options, visit www.entnet.org/mips-reporting. Make sure to consider your reporting method, practice size, patient mix, and performance period to choose the reporting period and measures that best suit you. You can access a full list of the measures at www.qpp.cms.gov.


To satisfy the Test reporting option for 2017, Eligible Clinicians (ECs) can choose to report one quality measure.

To satisfy the Partial and Full reporting options, ECs are required to select up to six (6) measures, including one (1) outcome measure (or high priority measure if outcome measure not available).

The Academy has identified 40 measures that may be applicable to Otolaryngologists for MIPS reporting.

These measures assess care in the following clinical areas:

  • Acute Otitis Externa #91, 93
  • Adult Sinusitis #331, 332, 333, 334
  • Sleep Apnea #276, 277, 278, 279
  • Asthma #398, 444
  • Surgery #355, 356, 357, 358
  • Falls #154, 155
  • Opioid Therapy #408, 412, 414
  • Perioperative Care and Screening #21, 23
  • Preventive Care and Screening #110, 111, 128, 226, 317, 431
  • Other #46, 47, 65, 66, 130, 131,
  • 238, 265, 402, 404, 435

The Reg-ent℠ Clinical Data Registry offers additional otolaryngology-specific measures for MIPS reporting via Qualified Clinical Data Registry (QCDR). For additional details on available Reg-ent℠ measures, visit: www.entnet.org/reg-ent-measures.


The Advancing Care Information (ACI) score is the combined total of the following three scores: the required Base score (50%); the Performance score (up to 90%); and a bonus score (up to 15%). Clinicians must report the base score to get any credit for the ACI category.

In 2017, there are two measure set options for reporting:

  • 2014 or 2015 Edition Technology: 2017 Advancing Care Information Transition Objectives and Measures
  • 2015 Edition Technology: Advancing Care Information Objectives and Measures

Required base score measures include:

  • Security Risk Analysis: All Editions
  • e-Prescribing: All Editions
  • Provide Patient Access: All Editions
  • Send a Summary of Care: 2015 Edition Only
  • Request/Accept Summary of Care: 2015 Edition Only
  • Health Information Exchange: 2014 Edition Only

ECs using 2015 edition technology may choose up to 9 additional performance score measures while ECs using 2014 or 2015 edition technology may choose up to 7 additional performance score measures. Additional details for the performance score measures are available at https://qpp.cms.gov/measures/aci.

Bonus points are available for ECs reporting to one or more designated public health and clinical data registry and reporting certain improvement activities using Certified Electronic Health Record Technology (CEHRT).


In 2017, ECs are required to attest to completing up to four improvement activities adding up to a total score of 40 points. High weighted activities are worth 20 points while medium weighted activities are worth 10 points. ECs can choose from 92 different activities in eight (8) different subcategories.

Improvement activity subcategories include: A full list of improvement activities and details may be found at https://qpp.cms.gov/measures/ia.

  • Achieving Health Equity
  • Behavioral and Mental Health
  • Beneficiary Engagement
  • Care Coordination
  • Emergency Response & Preparedness
  • Expanded Practice Access
  • Patient Safety & Practice Assessment
  • Population Management


The Academy’s Reg-ent℠ Clinical Data Registry provides participating members the capabilities to report on the three required categories of MIPS 2017: quality, ACI, and improvement activities. Please visit www.reg-ent.org to learn.

See MIPS for ENTs resource