2026 MIPS Measure #497: Preventive Care and Wellness (composite)

Percentage of patients who received age- and sex-appropriate preventive screenings and wellness services. This measure is a composite of seven component measures that are based on recommendations for preventive care by the U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), American Association of Clinical Endocrinology (AACE), and American College of Endocrinology (ACE).

This composite measure is to be submitted a minimum of once per performance period for patients seen during the performance period. However, the individual performance rates have different submission frequencies. This composite measure is intended to reflect the quality of services provided for preventative care and wellness. This composite measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. For accountability reporting in the CMS MIPS program, all seven performance rates must be submitted, and a weighted average will be used for performance.

This measure will be calculated with 7 performance rates:

1) Percentage of patients who received an influenza immunization or who reported previous receipt of an influenza immunization

2) Percentage of patients 65 years of age or older who received a pneumococcal vaccination on or after their 19th birthday

3) Percentage of patients with a mammogram during the 27 months prior to the end of the measurement period

4) Percentage of patients with one or more appropriate colorectal cancer screenings

5) Percentage of patients with a documented BMI, with follow-up plan if applicable, during the encounter or during the previous 12 months

6) Percentage of patients screened for tobacco use and, if identified as a tobacco user, received cessation intervention during the encounter or within the previous six months

7) Percentage of visits where patients were screened for high blood pressure with a documented follow-up plan, as indicated

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable except for Submission Criteria 5 and Submission Criteria 7. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

SUBMISSION CRITERIA 1: ALL PATIENTS WHO WERE SCREENED FOR INFLUENZA VACCINATION
DENOMINATOR (SUBMISSION CRITERIA 1):
All patients aged 6 months and older seen for a visit during the measurement period
DENOMINATOR NOTE: For the purposes of the program, in order to submit on the flu season 2024-2025, the patient must have a qualifying encounter between January 1 and March 31, 2025. In order to submit on the flu season 2025-2026, the patient must have a qualifying encounter between October 1 and December 31, 2025. A qualifying encounter needs to occur within the flu season that is being submitted; any additional encounter(s) may occur at any time within the measurement period.
*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
SUBMISSION CRITERIA 2: ALL PATIENTS WHO WERE SCREENED FOR PNEUMOCOCCAL VACCINATION STATUS FOR OLDER ADULTS
DENOMINATOR (SUBMISSION CRITERIA 2):
Patients 65 years of age and older with a visit during the measurement period
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
SUBMISSION CRITERIA 3: ALL PATIENTS WHO WERE SCREENED FOR BREAST CANCER
DENOMINATOR (SUBMISSION CRITERIA 3):
Women 41-74 years of age with a visit during the measurement period
DENOMINATOR NOTE: The intent of this measure component is that starting at age 40 women should have one or more mammograms every 24 months with a 3-month grace period. The intent of the exclusion for individuals age 66 and older residing in long-term care facilities, including nursing homes, is to exclude individuals who may have limited life expectancy and increased frailty where the benefit of the process may not exceed the risks. This exclusion is not intended as a clinical recommendation regarding whether the measures process is inappropriate for specific populations, instead the exclusion allows clinicians to engage in shared decision making with patients about the benefits and risks of screening when an individual has limited life expectancy.
To assess the age for exclusions, the patient’s age on the date of the encounter should be used. *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
SUBMISSION CRITERIA 4: ALL PATIENTS WHO WERE SCREENED FOR COLORECTAL CANCER SCREENING
DENOMINATOR (SUBMISSION CRITERIA 4):
Patients 45-75 years of age with a visit during the measurement period
DENOMINATOR NOTE: To assess the age for exclusions, the patient’s age on the date of the encounter should be used.
*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
SUBMISSION CRITERIA 5: ALL PATIENTS WHO WERE SCREENED FOR BODY MASS INDEX (BMI): SCREENING AND FOLLOW-UP PLAN
DENOMINATOR (SUBMISSION CRITERIA 5):
All patients aged 18 and older on the date of the encounter with at least one qualifying encounter during the measurement period
Definition:
Not Eligible for BMI Screening or Follow-Up Plan (Denominator Exclusions) – A patient is not eligible if one or more of the following reasons are documented:
Patients receiving palliative or hospice care on the date of the current encounter or any time prior to the current encounter
Patients who are pregnant on the date of the current encounter or any time during the measurement period prior to the current encounter
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
SUBMISSION CRITERIA 6: ALL PATIENTS WHO WERE SCREENED FOR TOBACCO USE: SCREENING AND CESSATION INTERVENTION
Submission Criteria 6 includes 3 performance rates: Only 6b is required for reporting:
A. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period
B. Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period
C. Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user
The denominator of Submission Criteria 6b is a subset of the resulting numerator for Submission Criteria 6a, as Submission Criteria 6b is limited to assessing if patients identified as tobacco users received an appropriate tobacco cessation intervention. For all patients, Submission Criteria 6a and 6c are applicable, but Submission Criteria 6b will only be applicable for those patients who are identified as tobacco users.
By separating this measure into various submission criteria, the MIPS eligible professional or MIPS eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 6b is used for the composite performance rate and is the only performance rate required for Submission Criteria 6 for the purposes of reporting this measure.
SUBMISSION CRITERIA 7: ALL PATIENTS WHO WERE SCREENED FOR HIGH BLOOD PRESSURE AND FOLLOW-UP DOCUMENTED
DENOMINATOR (SUBMISSION CRITERIA 7):
All patient visits for patients aged 18 years and older at the beginning of the measurement period
Definition:
Not Eligible for High Blood Pressure Screening (Denominator Exclusion) – Patient has an active diagnosis of hypertension prior to the current encounter
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases 1):
Patients aged ? 6 months
AND
Patient encounter during January thru March and/or October thru December (CPT or HCPCS): 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98979, 98980, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99421, 99422, 99423, 99429*, 99457, 99470, 99512*, G0438, G0439, G2250, G2251, G2252
AND NOT
DENOMINATOR EXCLUSIONS:
Hospice services provided to patient any time during the measurement period: M1303
OR
Anaphylaxis due to the vaccine on or before the date of the encounter: M1311

Denominator Criteria (Eligible Cases 2):
- Age: 41 to 74 years at beginning of measurement period
- Encounter during performance period using eligible CPT/HCPCS codes (see full list)

DENOMINATOR EXCLUSIONS (EXCLUDE FROM MEASURE IF ANY):
1. M1280 – Bilateral mastectomy OR history of bilateral mastectomy OR evidence of right AND left unilateral mastectomy
2. M1303 – Hospice services anytime during measurement period
3. M1309 – Palliative care services anytime during measurement period
4. M1284 – Age ?66 in Institutional SNP OR residing in long-term care (POS 32,33,34,54,56) for >90 consecutive days during measurement period
5. M1291 – Age ?66 with frailty (claim/encounter) AND dementia medication dispensed during measurement period OR prior year
6. M1292 – Age ?66 with frailty (claim/encounter) AND advanced illness diagnosis during measurement period OR prior year

FRAILTY CODES (for M1291 & M1292):
- HCPCS/CPT: 99504, 99509, E0100–E0171, E0250–E0304, E0424–E0472, E0561–E0562, E1130–E1298, G0162, G0299–G0300, G0493–G0494, S0271, S0311, S9123–S9124, T1000–T1031
- ICD-10-CM: L89.000–L89.96 (pressure ulcers), M62.50, M62.81, M62.84, R26.2, R26.89, R26.9, R29.6, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64, W01.0XXA–W19.XXXS (falls), Y92.199, Z59.3, Z73.6, Z74.01–Z74.9, Z91.81, Z99.11, Z99.3, Z99.81, Z99.89

ADVANCED ILLNESS CODES (for M1292):
- ICD-10-CM: A81.00–A81.09 (Prion disease), C25.0–C25.9 (Pancreatic cancer), C71.0–C71.9 (Brain cancer), C77.0–C79.9 (Metastatic cancer), C91.00–C94.32 (Leukemias), F01.50–F04 (Dementia/Alzheimer's with various complications), F10.27, F10.96–F10.97 (Alcohol-related), G10 (Huntington's), G12.21, G20.A1–G20.C (Parkinson's), G30.0–G31.83 (Alzheimer's/other degeneration), G35.A–G35.D (Multiple sclerosis), I09.81, I11.0, I12.0, I13.0–I13.2 (Hypertensive kidney disease), I50.1–I50.9 (Heart failure), J43.0–J43.9 (Emphysema), J68.4, J84.10–J84.178 (Interstitial lung disease), J96.10–J96.92 (Respiratory failure), J98.2–J98.3 (Interstitial emphysema/compensatory emphysema), K70.10–K74.69 (Liver disease/cirrhosis), N18.5–N18.6 (CKD stage 4-5)

DEMENTIA EXCLUSION MEDICATIONS (for M1291):
- Cholinesterase inhibitors: Donepezil, Galantamine, Rivastigmine
- Miscellaneous CNS agents: Memantine
- Dementia combinations: Donepezil-memantine

KEY TAKEAWAY:
Patient qualifies for measure if age 41-74 + eligible visit – EXCLUDE if any of M1280 (bilateral mastectomy), M1303 (hospice), M1309 (palliative), M1284 (long-term care >90d), M1291 (frailty + dementia meds), M1292 (frailty + advanced illness), or POS for long-term care exclusions.
BREAST CANCER SCREENING (BCS) MEASURE – M-CODES – SUMMARY:

Denominator Criteria (Eligible Cases 3):
- Age: 41 to 74 years at the beginning of the measurement period
- Patient encounter during performance period using eligible CPT/HCPCS codes:
98000–98016, 98979–98980, 99202–99215, 99341–99350,
99386*, 99387*, 99396*, 99397*, 99421–99423, 99457, 99470,
G0438, G0439, G2250–G2252

DENOMINATOR EXCLUSIONS (EXCLUDE IF ANY):

1. M1280 – Bilateral mastectomy
- History of bilateral mastectomy
- OR evidence of right AND left unilateral mastectomy

2. M1303 – Hospice services
- Any time during the measurement period

3. M1309 – Palliative care services
- Any time during the measurement period

4. M1284 – Long-term care (age ?66)
- Institutional SNP OR
- Residing in long-term care with POS 32, 33, 34, 54, or 56
- For more than 90 consecutive days during the measurement period

5. M1291 – Frailty + Dementia (age ?66)
- At least one claim/encounter for frailty during measurement period
- AND a dispensed medication for dementia during measurement period OR prior year

6. M1292 – Frailty + Advanced Illness (age ?66)
- At least one claim/encounter for frailty during measurement period
- AND an advanced illness diagnosis during measurement period OR prior year

FRAILTY CODES (for M1291, M1292):
- CPT/HCPCS: 99504, 99509, E0100–E0171, E0250–E0304, E0424–E0472, E0561–E0562, E1130–E1298, G0162, G0299–G0300, G0493–G0494, S0271, S0311, S9123–S9124, T1000–T1031
- ICD-10-CM: L89.000–L89.96 (pressure ulcers), M62.50, M62.81, M62.84, R26.2, R26.89, R26.9, R29.6, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64, W01.0XXA–W19.XXXS (falls), Y92.199, Z59.3, Z73.6, Z74.01–Z74.9, Z91.81, Z99.11, Z99.3, Z99.81, Z99.89

ADVANCED ILLNESS CODES (for M1292):
- ICD-10-CM: A81.00–A81.09, C25.0–C25.9, C71.0–C71.9, C77.0–C79.9, C91.00–C94.32, F01.50–F04, F10.27, F10.96–F10.97, G10, G12.21, G20.A1–G20.C, G30.0–G31.83, G35.A–G35.D, I09.81, I11.0, I12.0, I13.0–I13.2, I50.1–I50.9, J43.0–J43.9, J68.4, J84.10–J84.178, J96.10–J96.92, J98.2–J98.3, K70.10–K74.69, N18.5–N18.6

DEMENTIA EXCLUSION MEDICATIONS (for M1291):
- Cholinesterase inhibitors: Donepezil, Galantamine, Rivastigmine
- Miscellaneous CNS agents: Memantine
- Dementia combinations: Donepezil-memantine

KEY TAKEAWAY:
Patient qualifies if age 41–74 + eligible visit – EXCLUDE if any of:
M1280 (bilateral mastectomy),
M1303 (hospice),
M1309 (palliative),
M1284 (long-term care >90 days),
M1291 (frailty + dementia meds),
M1292 (frailty + advanced illness),
or POS for long-term care exclusions.

Denominator Criteria (Eligible Cases 4):
- Age: 45 to 75 years on date of encounter
- Patient encounter during performance period using eligible CPT/HCPCS codes:
98000–98016, 98979–98980, 99202–99215, 99341–99350,
99386*, 99387*, 99396*, 99397*, 99421–99423, 99457, 99470,
G0438, G0439, G2250–G2252

DENOMINATOR EXCLUSIONS (EXCLUDE IF ANY):

1. M1295 – Total colectomy or colorectal cancer
- Diagnosis or past history of total colectomy
- OR diagnosis or past history of colorectal cancer

2. M1303 – Hospice services
- Any time during the measurement period

3. M1309 – Palliative care services
- Any time during the measurement period

4. M1284 – Long-term care (age ?66)
- Institutional SNP OR
- Residing in long-term care with POS 32, 33, 34, 54, or 56
- For more than 90 consecutive days during the measurement period

5. M1291 – Frailty + Dementia (age ?66)
- At least one claim/encounter for frailty during measurement period
- AND a dispensed medication for dementia during measurement period OR prior year

6. M1292 – Frailty + Advanced Illness (age ?66)
- At least one claim/encounter for frailty during measurement period
- AND an advanced illness diagnosis during measurement period OR prior year

FRAILTY CODES (for M1291, M1292):
- CPT/HCPCS: 99504, 99509, E0100–E0171, E0250–E0304, E0424–E0472, E0561–E0562, E1130–E1298, G0162, G0299–G0300, G0493–G0494, S0271, S0311, S9123–S9124, T1000–T1031
- ICD-10-CM: L89.000–L89.96 (pressure ulcers), M62.50, M62.81, M62.84, R26.2, R26.89, R26.9, R29.6, R53.1, R53.81, R54, R62.7, R63.4, R63.6, R64, W01.0XXA–W19.XXXS (falls), Y92.199, Z59.3, Z73.6, Z74.01–Z74.9, Z91.81, Z99.11, Z99.3, Z99.81, Z99.89

ADVANCED ILLNESS CODES (for M1292):
- ICD-10-CM: A81.00–A81.09, C25.0–C25.9, C71.0–C71.9, C77.0–C79.9, C91.00–C94.32, F01.50–F04, F10.27, F10.96–F10.97, G10, G12.21, G20.A1–G20.C, G30.0–G31.83, G35.A–G35.D, I09.81, I11.0, I12.0, I13.0–I13.2, I50.1–I50.9, J43.0–J43.9, J68.4, J84.10–J84.178, J96.10–J96.92, J98.2–J98.3, K70.10–K74.69, N18.5–N18.6

DEMENTIA EXCLUSION MEDICATIONS (for M1291):
- Cholinesterase inhibitors: Donepezil, Galantamine, Rivastigmine
- Miscellaneous CNS agents: Memantine
- Dementia combinations: Donepezil-memantine

KEY TAKEAWAY:
Patient qualifies if age 45–75 + eligible visit – EXCLUDE if any of:
M1295 (total colectomy or colorectal cancer),
M1303 (hospice),
M1309 (palliative),
M1284 (long-term care >90 days),
M1291 (frailty + dementia meds),
M1292 (frailty + advanced illness),
or POS for long-term care exclusions.
Denominator Criteria (Eligible Cases 5):
Patients aged ?18 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99424, 99491, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447, G0473
WITHOUT
Encounters conducted via telehealth: M1426
WITHOUT
Place of Service (POS): 12
AND NOT
DENOMINATOR EXCLUSIONS:
Documentation stating the patient has received or is currently receiving palliative or hospice care:M1307
OR
Documentation of patient pregnancy anytime during the measurement period prior to and including the current encounter: M1298
Denominator Criteria (Eligible Cases 6):
Patients aged ? 12 years on date of encounter
AND
At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92622, 92625, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98979, 98980, 99024, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99421, 99422, 99423, 99457, 99470, G0270, G0271, G2250, G2251, G2252
OR
At least one preventive encounter during the performance period (CPT or HCPCS): 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Hospice services provided to patient any time during the measurement period: M1303

Denominator Criteria (Eligible Cases 7):
Patients aged ? 18 years at the beginning of the measurement period
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 92532, 92534, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92622, 92625, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99236, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99424, 99491, D3921, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0270, G0402, G0438, G0439
WITHOUT
Encounters conducted via telehealth: M1426
AND NOT
DENOMINATOR EXCLUSION:
Patient not eligible due to active diagnosis of hypertension: M1290

PREVENTIVE CARE MEASURES – ALL 7 SUBMISSION CRITERIA – NUMERATOR OPTIONS ONLY:

SUBMISSION CRITERIA 1 – INFLUENZA VACCINATION SCREENING:
- M1299: Performance Met – Influenza immunization administered or previously received
- M1300: Denominator Exception – Influenza immunization not administered for documented reasons (medical, patient, or system)
- M1308: Performance Not Met – Influenza immunization not administered, reason not given

SUBMISSION CRITERIA 2 – PNEUMOCOCCAL VACCINATION STATUS (OLDER ADULTS):
- M1305: Performance Met – Patient received any pneumococcal conjugate or polysaccharide vaccine on or after 19th birthday and before end of measurement period
- M1304: Performance Not Met – Patient did not receive any pneumococcal vaccine on or after 19th birthday and before end of measurement period

SUBMISSION CRITERIA 3 – BREAST CANCER SCREENING (MAMMOGRAM):
- M1302: Performance Met – Screening, diagnostic, film, digital or digital breast tomosynthesis (3D) mammography results documented and reviewed
- M1285: Performance Not Met – Mammography results not documented and reviewed, reason not otherwise specified

SUBMISSION CRITERIA 4 – COLORECTAL CANCER SCREENING:
- M1277: Performance Met – Colorectal cancer screening results documented and reviewed
- M1315: Performance Not Met – Colorectal cancer screening results not documented and reviewed, reason not otherwise specified

SUBMISSION CRITERIA 5 – BMI SCREENING AND FOLLOW-UP PLAN:
- M1296: Performance Met – BMI documented within normal parameters, no follow-up plan required
- M1293: Performance Met – BMI documented above normal parameters AND follow-up plan documented
- M1287: Performance Met – BMI documented below normal parameters AND follow-up plan documented
- M1297: Denominator Exception – BMI not documented due to medical reason OR patient refusal
- M1286: Denominator Exception – BMI outside normal parameters, follow-up plan not completed for documented medical reason
- M1314: Performance Not Met – BMI not documented, no reason given
- M1276: Performance Not Met – BMI outside normal parameters, no follow-up plan documented, no reason given

SUBMISSION CRITERIA 6 – TOBACCO USE SCREENING AND CESSATION INTERVENTION:

Performance Rate A (Screening):
- M1283: Performance Met – Patient screened AND identified as tobacco user
- M1282: Performance Met – Patient screened AND identified as tobacco non-user
- M1312: Performance Not Met – Patient not screened for tobacco use

Performance Rate B (Cessation Intervention for Users):
- M1301: Performance Met – Tobacco user received cessation intervention (counseling and/or pharmacotherapy)
- M1289: Performance Not Met – Tobacco user did not receive cessation intervention

Performance Rate C (Screening + Cessation if User):
- M1310: Performance Met – Screened AND received cessation intervention if identified as tobacco user
- M1316: Performance Met – Current tobacco non-user
- M1313: Performance Not Met – Screening not performed OR cessation intervention not provided if user

SUBMISSION CRITERIA 7 – HIGH BLOOD PRESSURE SCREENING AND FOLLOW-UP:
- M1294: Performance Met – Normal BP reading documented, follow-up not required
- M1278: Performance Met – Elevated or Hypertensive BP reading documented AND indicated follow-up documented
- M1288: Denominator Exception – Documented reason for not screening or recommending follow-up
- M1281: Performance Not Met – BP reading not documented, reason not given
- M1279: Performance Not Met – Elevated/Hypertensive BP documented, indicated follow-up not documented, reason not given

PREVENTIVE CARE MEASURES – NUMERATOR OPTIONS ONLY (ALL 7 CRITERIA):

SUBMISSION CRITERIA 1 – INFLUENZA VACCINATION:
- M1299: Performance Met – Influenza immunization administered or previously received
- M1300: Denominator Exception – Influenza immunization not administered for documented reasons (medical, patient, or system)
- M1308: Performance Not Met – Influenza immunization not administered, reason not given

SUBMISSION CRITERIA 2 – PNEUMOCOCCAL VACCINATION:
- M1305: Performance Met – Patient received any pneumococcal conjugate or polysaccharide vaccine on or after 19th birthday and before end of measurement period
- M1304: Performance Not Met – Patient did not receive any pneumococcal vaccine on or after 19th birthday and before end of measurement period

SUBMISSION CRITERIA 3 – BREAST CANCER SCREENING (MAMMOGRAM):
- M1302: Performance Met – Screening, diagnostic, film, digital, or digital breast tomosynthesis (3D) mammography results documented and reviewed
- M1285: Performance Not Met – Mammography results not documented and reviewed, reason not otherwise specified

SUBMISSION CRITERIA 4 – COLORECTAL CANCER SCREENING:
- M1277: Performance Met – Colorectal cancer screening results documented and reviewed
- M1315: Performance Not Met – Colorectal cancer screening results not documented and reviewed, reason not otherwise specified

SUBMISSION CRITERIA 5 – BMI SCREENING AND FOLLOW?UP PLAN:
- M1296: Performance Met – BMI documented within normal parameters, no follow?up plan required
- M1293: Performance Met – BMI documented above normal parameters AND follow?up plan documented
- M1287: Performance Met – BMI documented below normal parameters AND follow?up plan documented
- M1297: Denominator Exception – BMI not documented due to medical reason OR patient refusal of height/weight measurement
- M1286: Denominator Exception – BMI outside normal parameters, follow?up plan not completed for documented medical reason
- M1314: Performance Not Met – BMI not documented, no reason given
- M1276: Performance Not Met – BMI outside normal parameters, no follow?up plan documented, no reason given

SUBMISSION CRITERIA 6 – TOBACCO USE SCREENING AND CESSATION INTERVENTION:

Performance Rate A (Screening):
- M1283: Performance Met – Patient screened AND identified as tobacco user
- M1282: Performance Met – Patient screened AND identified as tobacco non?user
- M1312: Performance Not Met – Patient not screened for tobacco use

Performance Rate B (Cessation Intervention for Users):
- M1301: Performance Met – Tobacco user received tobacco cessation intervention (counseling and/or pharmacotherapy)
- M1289: Performance Not Met – Tobacco user did not receive tobacco cessation intervention

Performance Rate C (Screening + Cessation if User):
- M1310: Performance Met – Screened AND received cessation intervention if identified as tobacco user
- M1316: Performance Met – Current tobacco non?user
- M1313: Performance Not Met – Screening not performed OR cessation intervention not provided if user

SUBMISSION CRITERIA 7 – HIGH BLOOD PRESSURE SCREENING AND FOLLOW?UP:
- M1294: Performance Met – Normal BP reading documented, follow?up not required
- M1278: Performance Met – Elevated or Hypertensive BP reading documented AND indicated follow?up documented
- M1288: Denominator Exception – Documented reason for not screening or recommending follow?up for high BP
- M1281: Performance Not Met – BP reading not documented, reason not given
- M1279: Performance Not Met – Elevated/Hypertensive BP documented, indicated follow?up not documented, reason not given

With rising rates of certain chronic conditions in the general population, wellness and preventive care have become increasingly important to improve outcomes and reduce costs. Research shows that performing the preventive services identified in the measure leads to identification of disease earlier in the care process (screenings) or prevention of disease (immunizations), which enables treatment to begin earlier, potentially improving patient outcomes. The composite measure can provide an opportunity for providers and patients to identify and manage a patient’s health risks for many preventable conditions. This measure assigns a single performance score reflecting overall eligible clinician delivery of age- and sex-appropriate preventive screenings and wellness services to their patients. The seven services in this measure are (1) influenza vaccination, (2) pneumococcal vaccination, (3) breast cancer screening, (4) colorectal-cancer screening, (5) body mass index screening and follow-up, (6) tobacco use screening and intervention, and (7) screening for high blood pressure and follow-up. The services contained in the measure are recommended by USPSTF, ACIP, and AACE/ACE and apply to the general population (rather than a specific age group with specific risks, for example, older adults with cardiovascular risk). Although increased use of preventive care services may cause a short-term increase in health care costs, it may result in better quality of life and care. A study of preventive services covered under the Affordable Care Act examined the extent to which lives could be saved if adults over 18 received them, including some addressed by this measure. The article states that preventive services ameliorate 9 of the 10 leading causes of death in America and could save at least 100,000 lives (Fox and Shaw 2015). Among the services referenced are screening for breast cancer, colon cancer, blood pressure, diabetes, and tobacco cessation, as well as influenza and pneumococcal vaccination. Higher rates of patient compliance with the appropriate and recommended preventive services could save additional lives and ensure better health outcomes.

Composites can overcome statistical challenges such as small sample sizes while reducing data burden for interpretability (Peterson et al., 2010; Samuel, 2014; van Doorn-Klomberg et al., 2012). Due to the condensed nature of the composite’s information, it is more feasible to track a broader, more comprehensive range of metrics than otherwise possible, making composites well suited for pay-for-performance incentives or consumer decisions about clinicians (Peterson et al., 2010). Composite measures are an important strategy to maintain data fidelity as they are more likely to be stable over time, making incentives less sensitive to individual measure performance (Martsolf, 2012; Prentice et al., 2016). Potential implementation of this composite measure not only provides a more comprehensive assessment of a clinician’s performance of preventive care than any single measure, but also provides CMS an opportunity to replace the individual measures in the program with a more robust measure, which aligns with the meaningful measure framework’s goal to include fewer, more robust measures in the program overall.