Tiffany Anne Bersani

Beaufort County Memorial Hospital NPI1669868444

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

82.59 out of 100

Score Breakdown

Quality Category Score 81.80
PI Category Score 68

 

IA Category Score 40
Cost Category Score 0
Total Patients: 17
Source of Scores: group

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_4 Depression screening
IA_EC_BMH_2 Tobacco use
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_18 Measurement and Improvement at the Practice and Panel Level
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 41 44 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 24 982 2 85 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 7 44 1 100 EHR
MIPS_EC_112_overall Breast Cancer Screening 81 142 4 93 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 79 153 4 92 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 59 44 2 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 35 623 2 98 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 47 64 2 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 15 1232 1 96 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 97 2371 4 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 89 1360 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 12 43 3 100 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 87 1360 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 73 88 EHR
MIPS_EC_309_overall Cervical Cancer Screening 92 1111 4 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 59 2180 4 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 30 43 2 100 EHR
PI_EC_EP_1 e-Prescribing 96 725 3 100 EHR
PI_EC_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_EC_HIE_1 Support Electronic Referral Loops By Sending Health Information 11 182 1 79 EHR
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 88 1650 4 99 EHR
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5 Clinical Data Registry Reporting