Ledy P Chestnut

Medical Grand Strand Regional Medical Center NPI1629332911

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 172
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_4 Engagement of patients through implementation of improvements in patient portal
IA_EC_BMH_2 Tobacco use
IA_EC_BMH_4 Depression screening
IA_EC_CC_13 Practice Improvements for Bilateral Exchange of Patient Information
IA_EC_PM_16 Implementation of medication management practice improvements
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
IA_EC_PSPA_6 Consultation of the Prescription Drug Monitoring Program
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 12 163 EHR
MIPS_EC_112_overall Breast Cancer Screening 40 389 2 93 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 69 861 4 85 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 31 163 2 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 90 678 4 92 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 27 997 2 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 90 163 4 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 99 2103 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 69 701 3 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 79 966 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 76 963 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 7 814 3 100 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 76 606 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 56 68 3 100 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 75 814 4 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 19 505 1 88 EHR