MIPS Cheat Sheet

HIGH PRIORITY MEASURES

EMIQ #1 TPA AND ENDOVASCULAR THERAPY CONSIDERED FOR CVA/TIA PATIENTS (≥ 18 y/o)

1. tPA should be considered within 4.5 hours of stroke symptom onset or last time
seen normal OR 3-hour window for any of the below:
a. ≥ 80 years old
b. Diabetic and previous CVAc. On Anticoagulants (not antiplatelets)
d. NIHSS ≥ 25
2. Interventional therapy should be considered within 24-hours of stroke symptom onset or last time seen normal
NOTE: Measure considered met if provider documents that both treatments were considered within recommended times of stroke symptom onset but patient not appropriate for therapy due to other medical reasons (no availability, patient refusal, patient deemed not candidate for either therapy).
EXCLUSION EXAMPLES: Documentation that symptoms fully resolved at initial evaluation, advanced directive indicating limited intervention.

EMIQ #2 Avoidance of Opiate RX for > 20 doses (all ages included)

Opiates should not be prescribed for greater than 20 tablets.

EMIQ #3 heart score used for treatment of patients with non-traumatic chest pain (≥ 30 y/o)

HEART (History, ECG, Age, Risk Factors, Troponin) Score or other cardiac stratification tool (i.e. EDACS) should be used for treatment of patients when:
1. a physician or APC lists primary diagnosis of non-traumatic chest pain AND
2. troponin ordered
EXCLUSION: Patient admitted to the cardiac cath lab directly from the ED, patient diagnosed with acute MI, or other indication documented for cardiac disease therefore stratification not indicated.

Download Full Quality Measures Here

Antibiotic Stewardship/Infection Control CON’T

#76 cvc placement (All Ages Included)

Antibiotics should not be prescribed for Uncomplicated Acute Bronchitis.
Needs following documented:
1. Maximal barrier technique
– Cap/Mask (physician)
– Sterile gown (physician)
– Sterile gloves (physician)
– Sterile full body drape (patient)
2. Hand Hygiene (Ideal is soap and water or alcohol based product)
3. Patient skin prepped
4. If ultrasound used, sterile cover needs to be documented
The statement “Maximal barrier technique followed, hand hygiene followed, patient to sterile techniques followed, proper skin prep performed, and sterile cover used for ultrasound probe.” would meet this measure. This statement or its elements should ideally be part of the procedure note.
EXCLUSION: CVC Insertion emergent and delay for full prep contraindicated.

#93 Otitis Externa (≥ 2 y/o)

1. Simple OE should not receive systemic antibiotics
2. Complicated OE may have systemic antibiotic (DM, immunocompromise, cellulitis,
other)

HEAD CT RULES

#415 minor blunt head trauma adult ( ≥ 18 y/o, normal ms)

unt head injury peds
( 2-17 y/o, Normal MS)
HIGH PRIORITY MEASURES Antibiotic Stewardship/Infection Control CON’T
pregnancy
#254
ultrasound Localization of Pregnancy in patients (14-50
y/o) with Vaginal Bleeding or Abdominal Pain/pelvic pain
Requires localization of pregnancy by ultrasound
EXCLUSIONS:
1. Pregnancy previously localized in office/other ER visit/other documented location
2. Pain not felt to be pregnancy related (Ex. Epigastric pain likely GERD)
Antibiotic Stewardship/Infection Control

Group I
LOC or Post-traumatic Amnesia
And one or more of the following:
1. GCS score < 15
2. Any headache
3. Age ≥ 60 y/o
4. Intoxication
5. Short term memory deficit
6. Any physical evidence trauma
above clavicles
7. Post trauma seizure
Group II
LOC or Post-traumatic Amnesia
And one or more of the following:
1. GCS score < 15
2. Any headache
3. Age ≥ 60 y/o
4. Intoxication
5. Short term memory deficit
6. Any physical evidence trauma
above clavicles
7. Post trauma seizure

Head CT Indications: One indication from Group I or Combination from Group II
NOTE: If LOC is unclear, document “Unclear LOC”, which meets the measure.
EXCLUSION EXAMPLES: Shunt, brain tumor, multi-trauma, pregnancy, Plavix,
Coumadin, Eliquis

#416 minor blunt head injury peds ( 2-17 y/o, Normal MS)

Low Risk Head Injury
PECARN RULES:No head CT if all of the following
1. No AMS (Agitated, somnolence, perseveration, slow responses)
2. No physical signs of basilar skull fracture
3. No LOC
4. No vomiting
5. No severe mechanism (MVC with ejection, passenger death, pedestrian/cyclist struck MVC, fell>5 ft, high impact to head, other documented high risk)
6. No severe headache
7. No GCS <15

PREGNANCY

#254 ultrasound Localization of Pregnancy in patients (14-50 y/o) with Vaginal Bleeding or Abdominal Pain/pelvic pain

Requires localization of pregnancy by ultrasound
EXCLUSIONS:
1. Pregnancy previously localized in office/other ER visit/other documented location
2. Pain not felt to be pregnancy related (Ex. Epigastric pain likely GERD)