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A MIPS topped-out measure is a quality measure where almost all reporting clinicians are already performing at a very high level — meaning there’s little room left for improvement, and performance rates are clustered near the top.
CMS calls a measure topped-out when:
- Median performance rate is 95% or higher, and
- Variation between high and low performers is minimal (often defined by CMS statistical testing)
Why CMS Flags Them
If nearly everyone scores near 100%, the measure stops being useful for distinguishing quality among clinicians. For example, if 99% of clinicians meet the standard for a measure, it’s not an effective differentiator for incentives.
Scoring Impact
- Alternative (flat) benchmarks are applied — so even perfect performance may not earn the full 10 points in the Quality category
- Instead, scores might be capped — e.g., perfect reporting on a topped-out measure could give only 7 points
- Once a measure is topped-out for 3 consecutive years, CMS may remove it from the MIPS inventory unless it’s clinically critical or tied to another policy requirement
An important part of MIPS is selecting the measures that fit best for your practice. Among the considerations when selecting measures is ‘Are they topped-out?’. Keeping up to date with the topped-out list can be helpful when selecting your measures or when evaluating an EHR system to see if they support measures that are best for your practice.
Here are the 19 quality measures that CMS is proposing to designate as “topped-out” for the 2026 performance year under the Physician Fee Schedule (PFS). These will receive flat, alternative benchmarks due to limited measure choice and high-performance ceilings in certain specialty sets and MVPs.
The following are the Quality IDs and descriptive titles:
- Quality ID 141: Primary Open-Angle Glaucoma — Reduction of IOP by 20% OR Documentation of a Plan of Care
- Quality ID 143: Oncology: Medical and Radiation – Pain Intensity Quantified (eCQM/MIPS CQM)
- Quality ID 144: Oncology: Medical and Radiation – Plan of Care for Pain (MIPS CQM)
- Quality ID 249: Barrett’s Esophagus (Medicare Part B Claims/MIPS CQM)
- Quality ID 250: Radical Prostatectomy Pathology Reporting (Medicare Part B Claims/MIPS CQM)
- Quality ID 320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (Medicare Part B Claims)
- Quality ID 350: Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy (MIPS CQM)
- Quality ID 351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation (MIPS CQM)
- Quality ID 360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High-Dose Radiation Imaging Studies: CT and Cardiac Nuclear Medicine Studies (MIPS CQM)
- Quality ID 364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines (MIPS CQM)
- Quality ID 395: Lung Cancer Reporting (Biopsy/Cytology Specimens) (Medicare Part B Claims/MIPS CQM)
- Quality ID 396: Lung Cancer Reporting (Resection Specimens) (MIPS CQM)
- Quality ID 397: Melanoma Reporting (Medicare Part B Claims/MIPS CQM)
- Quality ID 405: Appropriate Follow-Up Imaging for Incidental Abdominal Lesions (MIPS CQM)
- Quality ID 406: Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients (Medicare Part B Claims/MIPS CQM)
- Quality ID 430: Prevention of Post-Operative Nausea and Vomiting (PONV) — Combination Therapy (MIPS CQM)
- Quality ID 440: Skin Cancer: Biopsy Reporting Time — Pathologist to Clinician (MIPS CQM)
- Quality ID 463: Prevention of Post-Operative Vomiting (POV) — Combination Therapy (Pediatrics) (MIPS CQM)
- Quality ID 477: Multimodal Pain Management (MIPS CQM)
These measures will use the topped-out benchmark approach in scoring to avoid skewed incentives from measures that have reached high performance plateaus. The current “Topped-Out Measures” that are subject to a 7 point cap include:
- Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
- Coronary Artery Disease (CAD): Antiplatelet Therapy
- Coronary Artery Disease (CAD): Beta-Blocker Therapy Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF)
- Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Advance Care Plan
- Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
- Appropriate Treatment for Upper Respiratory Infection (URI)
- Appropriate Testing for Pharyngitis
- Diabetes: Eye Exam
- Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
- Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
- Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
- Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy
- Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
- Rheumatoid Arthritis (RA): Functional Status Assessment
- Rheumatoid Arthritis (RA): Glucocorticoid Management
- Stroke and Stroke Rehabilitation: Thrombolytic Therapy
- Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
- Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
- Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy
- Dementia: Functional Status Assessment
- Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease
- Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease
- Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
- Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery
- Calcification Regional Distribution Scoring
- DEXA/DXA and Fracture Risk Assessment for Patients with Osteopenia
- Documentation of Current Medications in the Medical Record
- Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care
- Oncology: Medical and Radiation – Plan of Care for Pain
- Falls: Plan of Care
- Elder Maltreatment Screen and Follow-Up Plan
- Functional Outcome Assessment
- Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
- Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
- Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
- Dementia: Education and Support of Caregivers for Patients with Dementia
- Rehabilitative Therapy Referral for Patients with Parkinson’s Disease
- Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
- Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
- Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
- Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
- Patient-Centered Surgical Risk Assessment and Communication
- Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
- Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
- Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
- Overuse of Imaging for the Evaluation of Primary Headache
- Skin Cancer: Biopsy Reporting Time – Clinician to Patient
- Incidental Coronary Artery Calcification Reported on Chest CT
- Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism
- Use of Quantitative Criteria for Oncologic FDG PET Imaging
- Biopsy Reporting Time to Clinician
- Prostate Cancer Reporting: Complete Analysis
- Avoidance of Opiates for Low Back Pain or Migraines
- Diabetic Macular Edema – Loss of Visual Acuity
- Use of Thyroid Imaging Reporting & Data System (TI-RADS) in Final Report to Stratify Thyroid Nodule Risk
- IVC Filter Management Confirmation
- Use of Breast Cancer Risk Score on Mammography
