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2019-MIPS-QualityMeasures-List_v3.2.xlsxCover Page
| 2019 Merit-based Incentive Payment System (MIPS) | |||||
| Quality Measures List | |||||
| 4/24/19 | |||||
| Version 3.2 |
Instructions
| Step-by-Step Instructions to Search for Quality Measures Using this Excel File |
| This spreadsheet is a tool that eligible clinicians can use to search for current 2019 quality measures. The third tab of this file, titled "2019 MIPS Quality Measures List" includes the full set of current measures reportable through any collection type, as of 2019. Eligible clinicians can use this resource to find measures in any number of ways and then then use the measure specification manuals to dive deeper into any given measure. For guidance on how to search for measures, please see step by step instructions on how to execute the following basic functions: 1. Search by measure number 2 Search by NQS domain 3. Search by collection type 4. Search using keywords |
| 1. Search by measure number |
| Step 1: Identify the type of measure number you are searching by (CMS, NQF, Quality) and click on the arrow below that program. |
| Step 2: Once the arrow is selected, a drop down menu will appear. Input the measure number you are searching for and select "OK." |
| Step 3: This excel function will filter out all other measures, leaving you with just the measure with the number you are searching for. |
| Step 4: To undo your search (so that you might search for something else), reclick the arrow that is filtered and select "Clear Filter From '…'." |
| 2. Search by NQS Domain |
| Step 1: Select the arrow below the NQS Domain header (in Column G). |
| Step 2: Once the arrow is selected, a drop down menu will appear. Select all NQS Domains you are searching for (e.g., Effective Clinical Care)and select "OK." |
| Step 3: This will filter out all other measures, leaving you only with measures in the NQS Domain you are searching for. |
| Step 4: To undo your search (so that you might search for something else), reclick the arrow that is filtered and select "Clear Filter From 'NQS Domain' ". |
| 3. Search by Collection Type |
| Step 1: Select the arrow below the collection type you are searching for |
| Step 2: Once the arrow is selected, a drop down menu will appear. Unselect the "-" so that only the "X" is marked. Then select "OK." |
| Step 3: This excel function will filter out all other measures, leaving you only with measures reportable via the chosen collection type. |
| Step 4: To undo your search (so that you might search for something else), reclick the arrow that is filtered and select "Clear Filter From 'MIPS CQM' ". |
| 4. Search using Keywords |
| Step 1: Select the arrow below the Measure Title column. |
| Step 2: Once the arrow is selected, a drop down menu will appear. Input a key word you are searching for (e.g., "Parkinson") and select "OK." |
| Step 3: This excel function will filter out all other measures, leaving you only with measures with the word "Parkinson" in the measure title. |
| Step 4: To undo your search (so that you might search for something else), reclick the arrow that is filtered and select "Measure Title' ". |
| Note: this same function can be conducted in the measure description column as well. |
2019 MIPS Quality Measures List
| Measure Number | Collection Type(s) | Specialty Measure Sets | Use in Other Reporting Program(s) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Measure Title | CMS eCQM ID | eCQM NQF | NQF | Quality Number (Q#) | Measure Description | NQS Domain | Measure Type | Meaningful Measure Area | High Priority | Appropriate Use | Primary Measure Steward | Medicare Part B Claims | CSV | eCQM | CMS Web Interface | Administrative Claims | MIPS CQM | Allergy/ Immunology | Anesthesiology | Cardiology | Electro-physiology Cardiac Specialist | Gastro-enterology | Dermatology | Emergency Medicine | Family Medicine | Internal Medicine | Obstetrics/ Gynecology | Ophthalmology | Orthopedic Surgery | Otolaryngology | Pathology | Pediatrics | Physical Medicine | Plastic Surgery | Preventive Medicine | Neurology | Mental/ Behavioral Health | Diagnostic Radiology | Interventional Radiology | Vascular Surgery | General Surgery | Thoracic Surgery | Urology | Oncology | Radiation Oncology | Hospitalists | Rheumatology | Nephrology | Infectious Disease | Neurosurgical | Podiatry | Physical Therapy/ Occupational Therapy | Geriatrics | Urgent Care | Skilled Nursing Facility | Dentistry | ACO(s) | Million Hearts | |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | CMS122v7 | N/A | 0059 | 001 | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period | Effective Clinical Care | Intermediate Outcome | Management of Chronic Conditions | X | - | National Committee for Quality Assurance | X | - | X | X | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | |
| Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | CMS135v7 | 0081e | 0081 | 005 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | N/A | N/A | 0067 | 006 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Heart Association | - | - | - | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | CMS145v7 | N/A | 0070 | 007 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | CMS144v7 | 0083e | 0083 | 008 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | - | - | |
| Anti-Depressant Medication Management | CMS128v7 | N/A | 0105 | 009 | Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) | Effective Clinical Care | Process | Prevention and Treatment of Opioid and Substance Use Disorders | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | CMS143v7 | N/A | 0086 | 012 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Physician Consortium for Performance Improvement | X | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | N/A | N/A | 0087 | 014 | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Academy of Ophthalmology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | CMS142v7 | N/A | 0089 | 019 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | Physician Consortium for Performance Improvement | X | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin | N/A | N/A | 0268 | 021 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis | Patient Safety | Process | Healthcare Associated Infections | X | X | American Society of Plastic Surgeons | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | X | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | N/A | N/A | N/A | 023 | Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Patient Safety | Process | Preventive Care | X | - | American Society of Plastic Surgeons | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | X | - | - | - | - | - | X | X | X | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | N/A | N/A | N/A | 024 | Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | N/A | N/A | 0046 | 039 | Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis | Effective Clinical Care | Process | Preventive Care | - | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | - | - | |
| Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | N/A | N/A | 0236 | 044 | Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision | Effective Clinical Care | Process | Medication Management | - | - | Centers for Medicare & Medicaid Services | - | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Medication Reconciliation Post-Discharge | N/A | N/A | 0097 | 046 | The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years of age and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record This measure is submitted as three rates stratified by age group: • Submission Criteria 1: 18-64 years of age • Submission Criteria 2: 65 years and older • Total Rate: All patients 18 years of age and older | Communication and Care Coordination | Process | Medication Management | X | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | |
| Advance Care Plan | N/A | N/A | 0326 | 047 | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Communication and Care Coordination | Process | Care is Personalized and Aligned with Patient’s Goals | X | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | X | - | X | - | - | X | X | X | - | X | X | - | - | X | - | X | X | - | - | - | X | X | X | X | X | - | X | X | X | - | - | - | - | X | - | X | - | - | - | |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | N/A | N/A | N/A | 048 | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Effective Clinical Care | Process | Preventive Care | - | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | N/A | N/A | N/A | 050 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Person and Caregiver-Centered Experience and Outcomes | Process | Management of Chronic Conditions | X | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | N/A | N/A | 0091 | 051 | Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Thoracic Society | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | N/A | N/A | 0102 | 052 | Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Thoracic Society | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | CMS154v7 | N/A | 0069 | 065 | Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | National Committee for Quality Assurance | - | - | X | - | - | X | - | - | - | - | - | - | - | X | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Appropriate Testing for Children with Pharyngitis | CMS146v7 | N/A | N/A | 066 | Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | National Committee for Quality Assurance | - | - | X | - | - | X | - | - | - | - | - | - | X | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | N/A | N/A | 0377 | 067 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Society of Hematology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | N/A | N/A | 0378 | 068 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Society of Hematology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Hematology: Multiple Myeloma: Treatment with Bisphosphonates | N/A | N/A | N/A | 069 | Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Society of Hematology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | N/A | N/A | N/A | 070 | Percentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Physician Consortium for Performance Improvement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | N/A | N/A | 2726 | 076 | Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed | Patient Safety | Process | Healthcare Associated Infections | X | - | American Society of Anesthesiologists | X | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | |
| Acute Otitis Externa (AOE): Topical Therapy | N/A | N/A | 0653 | 091 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American Academy of Otolaryngology – Head and Neck Surgery | X | - | - | - | - | X | - | - | - | - | - | - | X | X | X | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | N/A | N/A | 0654 | 093 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | American Academy of Otolaryngology – Head and Neck Surgery | X | - | - | - | - | X | - | - | - | - | - | - | X | X | X | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | CMS129v8 | N/A | 0389 | 102 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | N/A | N/A | 0390 | 104 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Urological Association Education and Research | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | CMS161v7 | N/A | 0104 | 107 | Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | Physician Consortium for Performance Improvement | - | - | X | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Osteoarthritis (OA): Function and Pain Assessment | N/A | N/A | N/A | 109 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain | Person and Caregiver-Centered Experience and Outcomes | Process | Patient's Experience of Care | X | - | American Academy of Orthopedic Surgeons | X | - | - | - | - | X | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Preventive Care and Screening: Influenza Immunization | CMS147v8 | N/A | 0041 | 110 | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | Community/Population Health | Process | Preventive Care | - | - | Physician Consortium for Performance Improvement | X | - | X | X | - | X | X | - | - | - | - | - | - | X | X | X | - | - | X | - | X | - | - | X | - | - | - | - | - | - | - | - | X | - | - | X | X | X | - | - | - | X | - | X | - | X | - | |
| Pneumococcal Vaccination Status for Older Adults | CMS127v7 | N/A | N/A | 111 | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | Community/Population Health | Process | Preventive Care | - | - | National Committee for Quality Assurance | X | - | X | - | - | X | X | - | - | - | - | - | - | X | X | X | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | - | X | X | X | - | - | - | X | - | - | - | - | - | |
| Breast Cancer Screening | CMS125v7 | N/A | 2372 | 112 | Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer | Effective Clinical Care | Process | Preventive Care | - | - | National Committee for Quality Assurance | X | - | X | X | - | X | - | - | - | - | - | - | - | X | - | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | |
| Colorectal Cancer Screening | CMS130v7 | N/A | 0034 | 113 | Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer | Effective Clinical Care | Process | Preventive Care | - | - | National Committee for Quality Assurance | X | - | X | X | - | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | |
| Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | N/A | N/A | 0058 | 116 | The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Diabetes: Eye Exam | CMS131v7 | N/A | 0055 | 117 | Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | National Committee for Quality Assurance | X | - | X | - | - | X | - | - | - | - | - | - | - | X | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | N/A | N/A | 0066 | 118 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Heart Association | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | |
| Diabetes: Medical Attention for Nephropathy | CMS134v7 | N/A | 0062 | 119 | The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | National Committee for Quality Assurance | - | - | X | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | N/A | N/A | 0417 | 126 | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months | Effective Clinical Care | Process | Preventive Care | - | - | American Podiatric Medical Association | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | N/A | N/A | 0416 | 127 | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing | Effective Clinical Care | Process | Preventive Care | - | - | American Podiatric Medical Association | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | CMS69v7 | N/A | 0421 | 128 | Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2 | Community/Population Health | Process | Preventive Care | - | - | Centers for Medicare & Medicaid Services | X | - | X | - | - | X | - | - | X | - | X | - | - | X | X | X | - | X | X | - | - | X | - | X | - | X | - | - | X | X | - | X | - | - | - | X | - | - | - | X | X | - | - | - | - | - | X | |
| Documentation of Current Medications in the Medical Record | CMS68v8 | N/A | 0419 | 130 | Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration | Patient Safety | Process | Medication Management | X | - | Centers for Medicare & Medicaid Services | X | - | X | - | - | X | X | - | X | - | X | X | - | X | X | X | X | X | X | - | - | X | X | X | X | X | - | - | X | X | X | X | X | - | X | X | X | X | X | - | X | X | X | - | - | - | - | |
| Pain Assessment and Follow-Up | N/A | N/A | 0420 | 131 | Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present | Communication and Care Coordination | Process | Patient's Experience of Care | X | - | Centers for Medicare & Medicaid Services | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | X | X | X | - | - | - | - | |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | CMS2v8 | N/A | 0418 | 134 | Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen | Community/Population Health | Process | Prevention, Treatment, and Management of Mental Health | - | - | Centers for Medicare & Medicaid Services | X | - | X | X | - | X | - | - | - | - | - | - | - | X | X | - | - | X | - | - | X | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | |
| Melanoma: Continuity of Care – Recall System | N/A | N/A | N/A | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment | Communication and Care Coordination | Structure | Preventive Care | X | - | American Academy of Dermatology | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Melanoma: Coordination of Care | N/A | N/A | N/A | 138 | Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | American Academy of Dermatology | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | N/A | N/A | 0563 | 141 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period | Communication and Care Coordination | Outcome | Management of Chronic Conditions | X | - | American Academy of Ophthalmology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Oncology: Medical and Radiation – Pain Intensity Quantified | CMS157v7 | N/A | 0384 | 143 | Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified | Person and Caregiver-Centered Experience and Outcomes | Process | Management of Chronic Conditions | X | - | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Oncology: Medical and Radiation – Plan of Care for Moderate to Severe Pain | N/A | N/A | 0383 | 144 | Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician | Person and Caregiver-Centered Experience and Outcomes | Process | Patient Focused Episode of Care | X | - | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | N/A | N/A | N/A | 145 | Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available) | Patient Safety | Process | Appropriate Use of Healthcare | X | - | American College of Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms | N/A | N/A | 0508 | 146 | Percentage of final reports for screening mammograms that are classified as “probably benign” | Efficiency and Cost Reduction | Process | Transfer of Health Information and Interoperability | X | - | American College of Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | N/A | N/A | N/A | 147 | Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | Society of Nuclear Medicine and Molecular Imaging | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Falls: Risk Assessment | N/A | N/A | 0101 | 154 | Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months | Patient Safety | Process | Preventable Healthcare Harm | X | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | X | X | - | - | X | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | |
| Falls: Plan of Care | N/A | N/A | 0101 | 155 | Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months | Communication and Care Coordination | Process | Preventable Healthcare Harm | X | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | X | X | - | - | X | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | |
| HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | CMS52v7 | N/A | 0405 | 160 | Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | N/A | N/A | 0129 | 164 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours | Effective Clinical Care | Outcome | Preventable Healthcare Harm | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | N/A | N/A | 0130 | 165 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention | Effective Clinical Care | Outcome | Healthcare Associated Infections | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Bypass Graft (CABG): Stroke | N/A | N/A | 0131 | 166 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours | Effective Clinical Care | Outcome | Preventable Healthcare Harm | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | N/A | N/A | 0114 | 167 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis | Effective Clinical Care | Outcome | Preventable Healthcare Harm | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | N/A | N/A | 0115 | 168 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason | Effective Clinical Care | Outcome | Preventable Healthcare Harm | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rheumatoid Arthritis (RA): Tuberculosis Screening | N/A | N/A | N/A | 176 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who havedocumentation of a tuberculosis (TB) screening performed and results interpreted within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD) | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American College of Rheumatology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | N/A | N/A | N/A | 177 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity at ≥50% of encounters for RA for each patient during the measurement year | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American College of Rheumatology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Rheumatoid Arthritis (RA): Functional Status Assessment | N/A | N/A | N/A | 178 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months | Effective Clinical Care | Process | Patient's Experience of Care | - | - | American College of Rheumatology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | N/A | N/A | N/A | 179 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American College of Rheumatology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Rheumatoid Arthritis (RA): Glucocorticoid Management | N/A | N/A | N/A | 180 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American College of Rheumatology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Elder Maltreatment Screen and Follow-Up Plan | N/A | N/A | N/A | 181 | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen | Patient Safety | Process | Preventive Care | X | - | Centers for Medicare & Medicaid Services | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | X | - | - | - | |
| Functional Outcome Assessment | N/A | N/A | 2624 | 182 | Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies | Communication and Care Coordination | Process | Functional Outcomes | X | - | Centers for Medicare & Medicaid Services | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | N/A | N/A | 0659 | 185 | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy | Communication and Care Coordination | Process | Appropriate Use of Healthcare | X | X | American Gastroenterological Association | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | N/A | N/A | N/A | 187 | Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well | Effective Clinical Care | Process | Medication Management | - | - | American Heart Association | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | CMS133v7 | N/A | 0565 | 191 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery | Effective Clinical Care | Outcome | Management of Chronic Conditions | X | - | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | CMS132v7 | N/A | 0564 | 192 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence | Patient Safety | Outcome | Management of Chronic Conditions | X | - | Physician Consortium for Performance Improvement | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Radiology: Stenosis Measurement in Carotid Imaging Reports | N/A | N/A | 0507 | 195 | Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement | Effective Clinical Care | Process | Preventable Healthcare Harm | - | - | American College of Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | N/A | N/A | 0409 | 205 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | |
| Functional Status Change for Patients with Knee Impairments | N/A | N/A | 0422 | 217 | A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Functional Status Change for Patients with Hip Impairments | N/A | N/A | 0423 | 218 | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | N/A | N/A | 0424 | 219 | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Functional Status Change for Patients with Low Back Impairments | N/A | N/A | 0425 | 220 | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Functional Status Change for Patients with Shoulder Impairments | N/A | N/A | 0426 | 221 | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.).The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | N/A | N/A | 0427 | 222 | A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.) The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Functional Status Change for Patients with General Orthopedic Impairments | N/A | N/A | 0428 | 223 | A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) | Communication and Care Coordination | Patient Reported Outcome | Functional Outcomes | X | - | Focus on Therapeutic Outcomes, Inc. | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | |
| Radiology: Reminder System for Screening Mammograms | N/A | N/A | 0509 | 225 | Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram | Communication and Care Coordination | Structure | Preventive Care | X | - | American College of Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | CMS138v7 | N/A | 0028 | 226 | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user | Community/Population Health | Process | Prevention and Treatment of Opioid and Substance Use Disorders | - | - | Physician Consortium for Performance Improvement | X | - | X | X | - | X | X | - | X | - | X | X | - | X | X | X | X | X | X | - | - | X | X | X | X | X | - | - | X | X | X | X | X | - | - | X | - | - | X | X | - | - | X | - | - | X | X | |
| Controlling High Blood Pressure | CMS165v7 | N/A | 0018 | 236 | Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period | Effective Clinical Care | Intermediate Outcome | Management of Chronic Conditions | X | - | National Committee for Quality Assurance | X | - | X | X | - | X | - | - | X | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | X | |
| Use of High-Risk Medications in the Elderly | CMS156v7 | N/A | 0022 | 238 | Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication 2) Percentage of patients who were ordered at least two of the same high-risk medication | Patient Safety | Process | Medication Management | X | - | National Committee for Quality Assurance | - | - | X | - | - | X | X | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | - | - | |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | CMS155v7 | N/A | 0024 | 239 | Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. • Percentage of patients with height, weight, and body mass index (BMI) percentile documentation • Percentage of patients with counseling for nutrition • Percentage of patients with counseling for physical activity | Community/Population Health | Process | Preventive Care | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Childhood Immunization Status | CMS117v7 | N/A | 0038 | 240 | Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday | Community/Population Health | Process | Preventive Care | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | N/A | N/A | 0643 | 243 | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program | Communication and Care Coordination | Process | Preventive Care | X | - | American College of Cardiology Foundation | - | - | - | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | |
| Barrett’s Esophagus | N/A | N/A | 1854 | 249 | Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia | Effective Clinical Care | Process | Transfer of Health Information and Interoperability | - | - | College of American Pathologists | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Radical Prostatectomy Pathology Reporting | N/A | N/A | 1853 | 250 | Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status | Effective Clinical Care | Process | Transfer of Health Information and Interoperability | - | - | College of American Pathologists | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | N/A | N/A | N/A | 254 | Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location | Effective Clinical Care | Process | Preventive Care | - | - | American College of Emergency Physicians | X | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | N/A | N/A | N/A | 255 | Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED) | Effective Clinical Care | Process | Preventive Care | - | - | American College of Emergency Physicians | X | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | N/A | N/A | N/A | 258 | Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) | Patient Safety | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | N/A | N/A | N/A | 259 | Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) | Patient Safety | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | N/A | N/A | N/A | 260 | Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 | Patient Safety | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | N/A | N/A | N/A | 261 | Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | Audiology Quality Consortium | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Image Confirmation of Successful Excision of Image-Localized Breast Lesion | N/A | N/A | N/A | 262 | Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy | Patient Safety | Process | Preventable Healthcare Harm | X | - | American Society of Breast Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | N/A | N/A | N/A | 264 | The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure | Effective Clinical Care | Process | Appropriate Use of Healthcare | - | - | American Society of Breast Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Biopsy Follow-Up | N/A | N/A | N/A | 265 | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | American Academy of Dermatology | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | N/A | N/A | N/A | 268 | All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Academy of Neurology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | N/A | N/A | N/A | 271 | Percentage of patients regardless of age with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the year prior and current year are considered adequately screened to prevent overuse of X-ray assessment | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Gastroenterological Association | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | N/A | N/A | N/A | 275 | Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Gastroenterological Association | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Sleep Apnea: Severity Assessment at Initial Diagnosis | N/A | N/A | N/A | 277 | Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Academy of Sleep Medicine | - | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | N/A | N/A | N/A | 279 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American Academy of Sleep Medicine | - | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Dementia: Cognitive Assessment | CMS149v7 | N/A | 2872 | 281 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | Physician Consortium for Performance Improvement | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Dementia: Functional Status Assessment | N/A | N/A | N/A | 282 | Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | N/A | N/A | N/A | 283 | Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | N/A | N/A | N/A | 286 | Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources | Patient Safety | Process | Prevention, Treatment, and Management of Mental Health | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Dementia: Education and Support of Caregivers for Patients with Dementia | N/A | N/A | N/A | 288 | Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months | Communication and Care Coordination | Process | Prevention, Treatment, and Management of Mental Health | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease | N/A | N/A | N/A | 290 | Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms in the past 12 months | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease | N/A | N/A | N/A | 291 | Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 months | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Parkinson’s Disease: Rehabilitative Therapy Options | N/A | N/A | N/A | 293 | Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 months | Communication and Care Coordination | Process | Management of Chronic Conditions | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | N/A | N/A | N/A | 303 | Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | American Academy of Ophthalmology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | N/A | N/A | N/A | 304 | Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey | Person and Caregiver-Centered Experience and Outcomes | Patient Engagement/Experience | Functional Outcomes | X | - | American Academy of Ophthalmology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | CMS137v7 | N/A | 0004 | 305 | Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit | Effective Clinical Care | Process | Prevention and Treatment of Opioid and Substance Use Disorders | X | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cervical Cancer Screening | CMS124v7 | N/A | 0032 | 309 | Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years | Effective Clinical Care | Process | Preventive Care | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Chlamydia Screening for Women | CMS153v7 | N/A | 0033 | 310 | Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period | Community/Population Health | Process | Preventive Care | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | CMS22v7 | N/A | N/A | 317 | Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated | Community/Population Health | Process | Preventive Care | - | - | Centers for Medicare & Medicaid Services | X | - | X | - | - | X | X | - | X | - | X | X | X | X | X | X | - | X | X | - | - | X | X | X | X | X | - | - | X | X | X | X | X | - | - | X | X | - | - | - | - | - | X | X | - | - | - | |
| Falls: Screening for Future Fall Risk | CMS139v7 | N/A | 0101 | 318 | Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period | Patient Safety | Process | Preventable Healthcare Harm | X | - | National Committee for Quality Assurance | - | - | X | X | - | - | - | - | - | - | - | - | - | X | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | X | - | - | - | - | - | X | - | |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | N/A | N/A | 0658 | 320 | Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Communication and Care Coordination | Process | Appropriate Use of Healthcare | X | X | American Gastroenterological Association | X | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| CAHPS for MIPs Clinician/Group Survey | N/A | N/A | 0005 & 0006 | 321 | The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: • Getting timely care, appointments, and information; • How well providers Communicate; • Patient’s Rating of Provider; • Access to Specialists; • Health Promotion & Education; • Shared Decision Making; • Health Status/Functional Status; • Courteous and Helpful Office Staff; • Care Coordination; and • Stewardship of Patient Resources | Person and Caregiver-Centered Experience and Outcomes | Patient Engagement/Experience | Functional Outcomes | X | - | Agency for Healthcare Research & Quality | - | X | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | N/A | N/A | N/A | 322 | Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period | Efficiency and Cost Reduction | Efficiency | Appropriate Use of Healthcare | X | X | American College of Cardiology | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | N/A | N/A | N/A | 323 | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status | Efficiency and Cost Reduction | Efficiency | Appropriate Use of Healthcare | X | X | American College of Cardiology | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | N/A | N/A | N/A | 324 | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment | Efficiency and Cost Reduction | Efficiency | Appropriate Use of Healthcare | X | X | American College of Cardiology | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | N/A | N/A | N/A | 325 | Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition | Communication and Care Coordination | Process | Prevention, Treatment, and Management of Mental Health | X | - | American Psychiatric Association | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | N/A | N/A | 1525 | 326 | Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | American College of Cardiology | X | - | - | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | |
| Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL | N/A | N/A | 1667 | 328 | Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL | Effective Clinical Care | Intermediate Outcome | Management of Chronic Conditions | X | - | Renal Physicians Association | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | |
| Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | N/A | N/A | N/A | 329 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated | Effective Clinical Care | Outcome | Appropriate Use of Healthcare | X | - | Renal Physicians Association | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | N/A | N/A | N/A | 330 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter | Patient Safety | Outcome | Appropriate Use of Healthcare | X | X | Renal Physicians Association | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | N/A | N/A | N/A | 331 | Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | American Academy of Otolaryngology – Head and Neck Surgery | - | - | - | - | - | X | - | - | - | - | - | - | X | X | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | N/A | N/A | N/A | 332 | Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | American Academy of Otolaryngology – Head and Neck Surgery | - | - | - | - | - | X | - | - | - | - | - | - | X | X | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | N/A | N/A | N/A | 333 | Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis | Efficiency and Cost Reduction | Efficiency | Appropriate Use of Healthcare | X | X | American Academy of Otolaryngology – Head and Neck Surgery | - | - | - | - | - | X | - | - | - | - | - | - | X | X | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse) | N/A | N/A | N/A | 335 | Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication | Patient Safety | Outcome | Appropriate Use of Healthcare | X | X | Centers for Medicare & Medicaid Services | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Maternity Care: Post-Partum Follow-Up and Care Coordination | N/A | N/A | N/A | 336 | Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning | Communication and Care Coordination | Process | Prevention, Treatment, and Management of Mental Health | X | - | Centers for Medicare & Medicaid Services | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier | N/A | N/A | N/A | 337 | Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test | Effective Clinical Care | Process | Preventive Care | - | - | American Academy of Dermatology | - | - | - | - | - | X | - | - | - | - | - | X | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| HIV Viral Load Suppression | N/A | N/A | 2082 | 338 | The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year | Effective Clinical Care | Outcome | Management of Chronic Conditions | X | - | Health Resources and Services Administration | - | - | - | - | - | X | X | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | |
| HIV Medical Visit Frequency | N/A | N/A | 2079 | 340 | Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits | Efficiency and Cost Reduction | Process | Management of Chronic Conditions | X | - | Health Resources and Services Administration | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | |
| Pain Brought Under Control Within 48 Hours | N/A | N/A | N/A | 342 | Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours | Person and Caregiver-Centered Experience and Outcomes | Outcome | End of Life Care According to Preferences | X | - | National Hospice and Palliative Care Organization | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Screening Colonoscopy Adenoma Detection Rate | N/A | N/A | N/A | 343 | The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy | Effective Clinical Care | Outcome | Preventive Care | X | - | American Society for Gastrointestinal Endoscopy | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | N/A | N/A | N/A | 344 | Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 | Effective Clinical Care | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive | N/A | N/A | 1543 | 345 | Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery | Effective Clinical Care | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive | N/A | N/A | 1540 | 346 | Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery | Effective Clinical Care | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive | N/A | N/A | 1534 | 347 | Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive | Patient Safety | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | N/A | N/A | N/A | 348 | Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | The Heart Rhythm Society | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | N/A | N/A | N/A | 350 | Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure | Communication and Care Coordination | Process | Care is Personalized and Aligned with Patient’s Goals | X | - | American Association of Hip and Knee Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | N/A | N/A | N/A | 351 | Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke) | Patient Safety | Process | Preventive Care | X | - | American Association of Hip and Knee Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | N/A | N/A | N/A | 352 | Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet | Patient Safety | Process | Healthcare Associated Infections | X | - | American Association of Hip and Knee Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | N/A | N/A | N/A | 353 | Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant | Patient Safety | Process | Transfer of Health Information and Interoperability | X | - | American Association of Hip and Knee Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Anastomotic Leak Intervention | N/A | N/A | N/A | 354 | Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | American College of Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Unplanned Reoperation within the 30 Day Postoperative Period | N/A | N/A | N/A | 355 | Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period | Patient Safety | Outcome | Admissions and Readmissions to Hospitals | X | - | American College of Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | N/A | N/A | N/A | 356 | Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure | Effective Clinical Care | Outcome | Admissions and Readmissions to Hospitals | X | - | American College of Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Surgical Site Infection (SSI) | N/A | N/A | N/A | 357 | Percentage of patients aged 18 years and older who had a surgical site infection (SSI) | Effective Clinical Care | Outcome | Healthcare Associated Infections | X | - | American College of Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Patient-Centered Surgical Risk Assessment and Communication | N/A | N/A | N/A | 358 | Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon | Person and Caregiver-Centered Experience and Outcomes | Process | Care is Personalized and Aligned with Patient’s Goals | X | - | American College of Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | X | - | - | - | - | - | X | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | N/A | N/A | N/A | 360 | Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study | Patient Safety | Process | Transfer of Health Information and Interoperability | X | X | American College of Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | N/A | N/A | N/A | 361 | Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements | Patient Safety | Structure | Transfer of Health Information and Interoperability | X | - | American College of Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes | N/A | N/A | N/A | 362 | Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study | Communication and Care Coordination | Structure | Transfer of Health Information and Interoperability | X | - | American College of Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | N/A | N/A | N/A | 364 | Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians) | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | X | American College of Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Follow-Up Care for Children Prescribed ADHD Medication (ADD) | CMS136v8 | N/A | 0108 | 366 | Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Depression Remission at Twelve Months | CMS159v7 | 0710e | 0710 | 370 | The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event | Effective Clinical Care | Outcome | Prevention, Treatment, and Management of Mental Health | X | - | Minnesota Community Measurement | - | - | X | X | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | X | - | |
| Depression Utilization of the PHQ-9 Tool | CMS160v7 | 0712e | N/A | 371 | The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter | Effective Clinical Care | Process | Prevention, Treatment, and Management of Mental Health | - | - | Minnesota Community Measurement | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Maternal Depression Screening | CMS82v6 | N/A | N/A | 372 | The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life | Community/Population Health | Process | Prevention, Treatment, and Management of Mental Health | - | - | National Committee for Quality Assurance | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Closing the Referral Loop: Receipt of Specialist Report | CMS50v7 | N/A | N/A | 374 | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | Centers for Medicare & Medicaid Services | - | - | X | - | - | X | X | - | X | - | X | X | - | X | X | X | X | X | X | - | - | X | - | X | X | X | - | X | X | X | X | X | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | |
| Functional Status Assessment for Total Knee Replacement | CMS66v7 | N/A | N/A | 375 | Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery | Person and Caregiver-Centered Experience and Outcomes | Process | Functional Outcomes | X | - | Centers for Medicare & Medicaid Services | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Functional Status Assessment for Total Hip Replacement | CMS56v7 | N/A | N/A | 376 | Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery | Person and Caregiver-Centered Experience and Outcomes | Process | Functional Outcomes | X | - | Centers for Medicare & Medicaid Services | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Functional Status Assessments for Congestive Heart Failure | CMS90v8 | N/A | N/A | 377 | Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments | Person and Caregiver-Centered Experience and Outcomes | Process | Functional Outcomes | X | - | Centers for Medicare & Medicaid Services | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Children Who Have Dental Decay or Cavities | CMS75v7 | N/A | N/A | 378 | Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period | Community/Population Health | Outcome | Preventive Care | X | - | Centers for Medicare & Medicaid Services | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | |
| Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | CMS74v8 | N/A | N/A | 379 | Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period | Effective Clinical Care | Process | Preventive Care | - | - | Centers for Medicare & Medicaid Services | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | CMS177v7 | 1365e | N/A | 382 | Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk | Patient Safety | Process | Prevention, Treatment, and Management of Mental Health | X | - | Physician Consortium for Performance Improvement | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | N/A | N/A | 1879 | 383 | Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months) | Patient Safety | Intermediate Outcome | Prevention, Treatment, and Management of Mental Health | X | - | Health Services Advisory Group | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | N/A | N/A | N/A | 384 | Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery | Effective Clinical Care | Outcome | Preventable Healthcare Harm | X | - | American Academy of Ophthalmology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | N/A | N/A | N/A | 385 | Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye | Effective Clinical Care | Outcome | Functional Outcomes | X | - | American Academy of Ophthalmology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | N/A | N/A | N/A | 386 | Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually | Person and Caregiver-Centered Experience and Outcomes | Process | End of Life Care According to Preferences | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | N/A | N/A | N/A | 387 | Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period | Effective Clinical Care | Process | Preventive Care | - | - | Physician Consortium for Performance Improvement | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) | N/A | N/A | N/A | 388 | Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | American Academy of Ophthalmology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Cataract Surgery: Difference Between Planned and Final Refraction | N/A | N/A | N/A | 389 | Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction | Effective Clinical Care | Outcome | Functional Outcomes | X | - | American Academy of Ophthalmology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | N/A | N/A | N/A | 390 | Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment | Person and Caregiver-Centered Experience and Outcomes | Process | Care is Personalized and Aligned with Patient’s Goals | X | - | American Gastroenterological Association | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Follow-Up After Hospitalization for Mental Illness (FUH) | N/A | N/A | 0576 | 391 | The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: • The percentage of discharges for which the patient received follow-up within 30 days after discharge. • The percentage of discharges for which the patient received follow-up within 7 days after discharge. | Communication and Care Coordination | Process | Prevention, Treatment, and Management of Mental Health | X | - | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | N/A | N/A | 2474 | 392 | Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender: • Submission Age Criteria 1: Females 18-64 years of age • Submission Age Criteria 2: Males 18-64 years of age • Submission Age Criteria 3: Females 65 years of age and older • Submission Age Criteria 4: Males 65 years of age and older | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | The Heart Rhythm Society | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | N/A | N/A | N/A | 393 | Infection rate following CIED device implantation, replacement, or revision | Patient Safety | Outcome | Healthcare Associated Infections | X | - | The Heart Rhythm Society | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Immunizations for Adolescents | N/A | N/A | 1407 | 394 | The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday | Community/Population Health | Process | Preventive Care | - | - | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | N/A | N/A | N/A | 395 | Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | College of American Pathologists | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Lung Cancer Reporting (Resection Specimens) | N/A | N/A | N/A | 396 | Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | College of American Pathologists | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Melanoma Reporting | N/A | N/A | N/A | 397 | Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | College of American Pathologists | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Optimal Asthma Control | N/A | N/A | N/A | 398 | Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation | Effective Clinical Care | Outcome | Management of Chronic Conditions | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | N/A | N/A | 3059 | 400 | Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection | Effective Clinical Care | Process | Preventive Care | - | - | Physician Consortium for Performance Improvement | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | N/A | N/A | N/A | 401 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission period | Effective Clinical Care | Process | Preventive Care | - | - | American Gastroenterological Association | - | - | - | - | - | X | - | - | - | - | X | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Tobacco Use and Help with Quitting Among Adolescents | N/A | N/A | N/A | 402 | The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user | Community/Population Health | Process | Prevention and Treatment of Opioid and Substance Use Disorders | - | - | National Committee for Quality Assurance | - | - | - | - | - | X | X | - | X | - | X | X | - | X | X | X | - | X | X | - | X | X | - | X | X | X | - | - | X | X | X | - | X | - | - | X | - | - | - | - | - | - | X | - | - | - | - | |
| Adult Kidney Disease: Referral to Hospice | N/A | N/A | N/A | 403 | Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care | Person and Caregiver-Centered Experience and Outcomes | Process | End of Life Care According to Preferences | X | - | Renal Physicians Association | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | |
| Anesthesiology Smoking Abstinence | N/A | N/A | N/A | 404 | The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure | Effective Clinical Care | Intermediate Outcome | Prevention and Treatment of Opioid and Substance Use Disorders | X | - | American Society of Anesthesiologists | - | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | N/A | N/A | N/A | 405 | Percentage of final reports for abdominal imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended • Liver lesion ≤ 0.5 cm • Cystic kidney lesion < 1.0 cm • Adrenal lesion ≤ 1.0 cm | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American College of Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | N/A | N/A | N/A | 406 | Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American College of Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Appropriate Treatment of Methicillin-Susceptible Staphylococcus Aureus (MSSA) Bacteremia | N/A | N/A | N/A | 407 | Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. Nafcillin, Oxacillin or Cefazolin) as definitive therapy | Effective Clinical Care | Process | Healthcare Associated Infections | X | X | Infectious Diseases Society of America | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | |
| Opioid Therapy Follow-up Evaluation | N/A | N/A | N/A | 408 | All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record | Effective Clinical Care | Process | Prevention and Treatment of Opioid and Substance Use Disorders | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | X | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Clinical Outcome Post Endovascular Stroke Treatment | N/A | N/A | N/A | 409 | Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention | Effective Clinical Care | Outcome | Management of Chronic Conditions | X | - | Society of Interventional Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Psoriasis: Clinical Response to Systemic Medications | N/A | N/A | N/A | 410 | Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment | Person and Caregiver-Centered Experience and Outcomes | Outcome | Management of Chronic Conditions | X | - | American Academy of Dermatology | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Depression Remission at Six Months | N/A | N/A | 0711 | 411 | The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 60 days) after an index event date | Effective Clinical Care | Outcome | Prevention, Treatment, and Management of Mental Health | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Documentation of Signed Opioid Treatment Agreement | N/A | N/A | N/A | 412 | All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record | Effective Clinical Care | Process | Prevention and Treatment of Opioid and Substance Use Disorders | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | X | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Door to Puncture Time for Endovascular Stroke Treatment | N/A | N/A | N/A | 413 | Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours | Effective Clinical Care | Intermediate Outcome | Patient Focused Episode of Care | X | - | Society of Interventional Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Evaluation or Interview for Risk of Opioid Misuse | N/A | N/A | N/A | 414 | All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record | Effective Clinical Care | Process | Prevention and Treatment of Opioid and Substance Use Disorders | X | - | American Academy of Neurology | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | X | - | - | - | X | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | N/A | N/A | N/A | 415 | Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care clinician who have an indication for a head CT | Efficiency and Cost Reduction | Efficiency | Appropriate Use of Healthcare | X | - | American College of Emergency Physicians | X | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | N/A | N/A | N/A | 416 | Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury | Efficiency and Cost Reduction | Efficiency | Appropriate Use of Healthcare | X | X | American College of Emergency Physicians | X | - | - | - | - | X | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive | N/A | N/A | 1523 | 417 | Percentage of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive | Patient Safety | Outcome | Appropriate Use of Healthcare | X | - | Society for Vascular Surgery | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Osteoporosis Management in Women Who Had a Fracture | N/A | N/A | 0053 | 418 | The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | X | X | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Overuse of Imaging for the Evaluation of Primary Headache | N/A | N/A | N/A | 419 | Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | American Academy of Neurology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | N/A | N/A | N/A | 420 | Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment | Effective Clinical Care | Patient Reported Outcome | Functional Outcomes | X | - | Society of Interventional Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | N/A | N/A | N/A | 421 | Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts | Effective Clinical Care | Process | Preventable Healthcare Harm | - | - | Society of Interventional Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | N/A | N/A | 2063 | 422 | Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse | Patient Safety | Process | Preventable Healthcare Harm | X | - | American Urogynecologic Society | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Perioperative Temperature Management | N/A | N/A | 2681 | 424 | Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | American Society of Anesthesiologists | - | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Photodocumentation of Cecal Intubation | N/A | N/A | N/A | 425 | The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination | Effective Clinical Care | Process | Transfer of Health Information and Interoperability | - | - | American Society for Gastrointestinal Endoscopy | X | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | N/A | N/A | N/A | 428 | Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines | Effective Clinical Care | Process | Preventable Healthcare Harm | - | - | American Urogynecologic Society | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | N/A | N/A | N/A | 429 | Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse | Patient Safety | Process | Preventive Care | X | - | American Urogynecologic Society | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | N/A | N/A | N/A | 430 | Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively | Patient Safety | Process | Preventive Care | X | - | American Society of Anesthesiologists | - | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | N/A | N/A | 2152 | 431 | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user | Community/Population Health | Process | Prevention and Treatment of Opioid and Substance Use Disorders | - | - | Physician Consortium for Performance Improvement | - | - | - | - | - | X | - | - | X | - | X | - | - | X | X | X | - | - | X | - | - | X | - | X | X | X | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | |
| Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | N/A | N/A | N/A | 432 | Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 30 days after surgery | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | American Urogynecologic Society | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | N/A | N/A | N/A | 433 | Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | American Urogynecologic Society | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair | N/A | N/A | N/A | 434 | Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | American Urogynecologic Society | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Quality of Life Assessment For Patients With Primary Headache Disorders | N/A | N/A | N/A | 435 | Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved | Effective Clinical Care | Patient Reported Outcome | Functional Outcomes | X | - | American Academy of Neurology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | N/A | N/A | N/A | 436 | Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique | Effective Clinical Care | Process | Appropriate Use of Healthcare | - | - | American College of Radiology/Ameri can Medical AssociationPhysician Consortium for Performance Improvement/ National Committee for Quality Assurance | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | N/A | N/A | N/A | 437 | Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure | Patient Safety | Outcome | Preventable Healthcare Harm | X | - | Society of Interventional Radiology | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | CMS347v2 | N/A | N/A | 438 | Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: *Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR *Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR *Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Centers for Medicare & Medicaid Services | - | - | X | X | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | |
| Age Appropriate Screening Colonoscopy | N/A | N/A | N/A | 439 | The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31 | Effective Clinical Care | Efficiency | Appropriate Use of Healthcare | X | X | American Gastroenterological Association | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician | N/A | N/A | N/A | 440 | Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist | Communication and Care Coordination | Process | Transfer of Health Information and Interoperability | X | - | American Academy of Dermatology | - | - | - | - | - | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | N/A | N/A | N/A | 441 | The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: • Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND • Most recent tobacco status is Tobacco Free -- AND • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND • Statin Use Unless Contraindicated | Effective Clinical Care | Intermediate Outcome | Management of Chronic Conditions | X | - | Wisconsin Collaborative for Healthcare Quality | - | - | - | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Persistence of Beta-Blocker Treatment After a Heart Attack | N/A | N/A | 0071 | 442 | The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with adiagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | X | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Non-Recommended Cervical Cancer Screening in Adolescent Females | N/A | N/A | N/A | 443 | The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer | Patient Safety | Process | Appropriate Use of Healthcare | X | X | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Medication Management for People with Asthma | N/A | N/A | N/A | 444 | The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period | Efficiency and Cost Reduction | Process | Medication Management | X | - | National Committee for Quality Assurance | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | N/A | N/A | 0119 | 445 | Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure | Effective Clinical Care | Outcome | Risk Adjusted Mortality | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Operative Mortality Stratified by the Five STS-EACTS Mortality Categories | N/A | N/A | 0733 | 446 | Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool | Patient Safety | Outcome | Risk Adjusted Mortality | X | - | Society of Thoracic Surgeons | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Appropriate Workup Prior to Endometrial Ablation | N/A | N/A | N/A | 448 | Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation | Communication and Care Coordination | Process | Appropriate Use of Healthcare | X | - | Centers for Medicare & Medicaid Services | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies | N/A | N/A | 1857 | 449 | Percentage of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies | Efficiency and Cost Reduction | Process | Preventable Healthcare Harm | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy | N/A | N/A | 1858 | 450 | Percentage of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving Trastuzumab | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | N/A | N/A | 1859 | 451 | Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed | Effective Clinical Care | Process | Appropriate Use of Healthcare | - | - | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | N/A | N/A | 1860 | 452 | Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies | Patient Safety | Process | Appropriate Use of Healthcare | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better) | N/A | N/A | 0210 | 453 | Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score – better) | N/A | N/A | N/A | 454 | Percentage of patients who died from cancer with more than one emergency department visit in the last 30 days of life | Effective Clinical Care | Outcome | Appropriate Use of Healthcare | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better) | N/A | N/A | 0213 | 455 | Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life | Effective Clinical Care | Outcome | Appropriate Use of Healthcare | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | |
| Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score – better) | N/A | N/A | 0215 | 456 | Percentage of patients who died from cancer not admitted to hospice | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) | N/A | N/A | 0216 | 457 | Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there | Effective Clinical Care | Outcome | End of Life Care According to Preferences | X | X | American Society of Clinical Oncology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| All-cause Hospital Readmission | N/A | N/A | 1789 | 458 | The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge | Communication and Care Coordination | Outcome | Admissions and Readmissions to Hospitals | X | - | Yale University | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | |
| Average Change in Back Pain Following Lumbar Discectomy/Laminotomy | N/A | N/A | N/A | 459 | The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Average Change in Back Pain Following Lumbar Fusion | N/A | N/A | N/A | 460 | The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had a lumbar fusion procedure | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Average Change in Leg Pain Following Lumbar Discectomy and/or Laminotomy | N/A | N/A | N/A | 461 | The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | CMS645v2 | N/A | N/A | 462 | Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater (indicated by HCPCS code) and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT | Effective Clinical Care | Process | Management of Chronic Conditions | - | - | Oregon Urology Institute | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) | N/A | N/A | N/A | 463 | Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively | Patient Safety | Process | Preventive Care | X | - | American Society of Anesthesiologists | - | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | N/A | N/A | 0657 | 464 | Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials | Effective Clinical Care | Process | Appropriate Use of Healthcare | X | X | American Academy of Otolaryngology – Head and Neck Surgery Foundation | - | - | - | - | - | X | - | - | - | - | - | - | - | X | - | - | - | - | X | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | X | - | - | - | - | |
| Uterine Artery Embolization Technique: Documenttion of Angigraphic Endpoints and Interrogation of Ovarian Arteries | N/A | N/A | N/A | 465 | The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries | Patient Safety | Process | Transfer of Health Information and Interoperability | X | - | Society of Interventional Radiology | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Developmental Screening in the First Three Years of Life | N/A | N/A | 1448 | 467 | The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months preceding or on their first, second or third birthday | Community/Population Health | Process | Preventive Care | - | - | Oregon Health & Science University | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | N/A | N/A | 3175 | 468 | Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment | Effective Clinical Care | Process | Prevention and Treatment of Opioid and Substance Use Disorders | X | X | University of Southern California | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | X | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Average Change in Functional Status Following Lumbar Fusion Surgery | N/A | N/A | 2643 | 469 | The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2. 1a) for patients 18 years of age and older who had a lumbar fusion procedure | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Average Change In Functional Status Following Total Knee Replacement Surgery | N/A | N/A | 2653 | 470 | The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery | N/A | N/A | N/A | 471 | The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | CMS249v1 | N/A | N/A | 472 | Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period. | Efficiency and Cost Reduction | Process | Appropriate Use of Healthcare | X | X | Centers for Medicare & Medicaid Services | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |
| Average Change in Leg Pain Following Lumbar Fusion Surgery | N/A | N/A | N/A | 473 | The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure | Person and Caregiver-Centered Experience and Outcomes | Patient Reported Outcome | Functional Outcomes | X | - | Minnesota Community Measurement | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | |
| Zoster (Shingles) Vaccination | N/A | N/A | N/A | 474 | The percentage of patients aged 50 years and older who have had the Shingrix zoster (shingles) vaccination. | Community/Population Health | Process | Preventive Care | - | - | PPRNet | - | - | - | - | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | X | - | - | - | X | X | - | - | - | X | - | X | - | - | - | |
| HIV Screening | CMS349v1 | N/A | N/A | 475 | Percentage of patients 15-65 years of age who have been tested for HIV within that age range | Community/Population Health | Process | Preventive Care | - | - | Centers for Disease Control and Prevention | - | - | X | - | - | - | - | - | - | - | - | - | - | X | X | X | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - |
&"Cambria,Bold"&6 2017 Measure's List&"Cambria,Regular" Page &P of &N
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&"Cambria,Bold"&6 2017 Measure's List&"Cambria,Regular" Page &P of &N
NQF_Q1 2014 Status
| PQRS Number | Measure Title | Measure Number | Measure Description | NQS Domain | Measure Type | Measure Developer/Steward | NQF Project Committee | NQF Cycle | NQF Endorsement Status | Annual Update Due Date | Comprehensive Review Due Date | Additional information (e.g., Testing Results, Revisions), including Month/Year Completed or Anticipated | Synopsis of NQF Endorsement Activity and/or NQF Communications since the most Recent Quarterly Update | ||||||||
| CMS | NQF | PQRS | #1 | #2 | #3 | Q2 2013 | Q1 2014 | Q2 2014 | Q3 2014 | Q4 2014 | |||||||||||
| - | AAD | ||||||||||||||||||||
| 265 | Biopsy Follow-Up | - | - | 0265 | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician | Communication and Care Coordination | Process | AAD | - | - | - | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 337 | Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier | - | - | 0337 | Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test | Effective Clinical Care | Process | AAD | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - Measure Testing planned for beginning Summer 2104, and then to be submitted for NQF endorsement | - |
| 137 | Melanoma: Continuity of Care | - | 0650 | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered at least once within a 12-month period into a recall system that includes: A target date for the next complete physical skin exam, & - A process to follow up with patients who either did not make an appointment within the specified time frame or who missed a scheduled appointment | Effective Clinical Care | Process | AAD | - | - | - | - | - | Full Endorsement | - | - | - | - | 2015 | Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall 2014 | - |
| 224 | Melanoma: Overutilization of Imaging Studies | - | 0562 | 224 | Percentage of patients with melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered. | Efficient Use of Healthcare Resources/Affordable Care | Process | AAD | - | - | - | - | - | Full Endorsement | - | - | - | - | 2015 | Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall 2014 | - |
| 138 | Melanoma: Coordination of Care | - | - | 138 | Percentage of patient visits, regardless of patient age, with a new occurrence of melanoma. They must have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis. | Care Coordination | Process | AAD | - | - | - | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| - | ACG | ||||||||||||||||||||
| 343 | Screening Colonoscopy Adenoma Detection Rate Measure | - | - | 343 | The percentage of patients age 50 years or older with at least one adenoma or other colorectal cancer precursor or colorectal cancer detected during screening colonoscopy | Effective Clinical Care | Outcome | ACG ASGE | ASGE ACG | AGA | Gastroenterology | - | N/A | Non-Endorsed/Planned Submission | - | - | - | - | Year or exact date TBD | Q2-submitting to NQF measure inventory pipeline | Q1-awaiting determination by NQF when measure can be scheduled for review |
| - | AAHKS | ||||||||||||||||||||
| 351 | Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | - | - | 0351 | Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of Deep Vein Thrombosis, Pulmonary Embolism, Myocardial Infarction, Arrhythmia and Stroke | Patient Safety | Process | AAHKS | - | - | AAHKS is a small specialty society with limited staff and resources. Due to the burdensome process of NQF measure endorsement, AAHKS is not currently capable of seeking NQF endorsement. (04/07/14) | - | - | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | - | - |
| 352 | Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | - | - | 0352 | Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet | Patient Safety | Process | AAHKS | - | - | - | - | - | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | - | - |
| 353 | Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | - | - | 353 | Percentage of patients regardless of age or gender undergoing total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of prosthetic implant | Patient Safety | Process | AAHKS | - | - | - | - | - | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | - | - |
| 350 | Total Knee Replacement: Shared Decision- Making: Trial of Conservative (Non-surgical) Therapy (04/07/14) | - | - | 350 | Percentange of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy prior to the procedure | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| - | AAN | ||||||||||||||||||||
| 289 | Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review | - | - | 0289 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | - |
| 290 | Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment | - | - | 0290 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | - |
| 291 | Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment | - | - | 291 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | - |
| 292 | Parkinson’s Disease: Querying about Sleep Disturbances | - | - | 292 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | - |
| 293 | Parkinson’s Disease: Rehabilitative Therapy Options | - | - | 293 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | - |
| 294 | Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed | - | - | 294 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: Q2 '2014 Update/revision to be initiated | - |
| 266 | Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies) | - | - | 266 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: 'Q4 2014 Update complete | - |
| 267 | Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome | - | - | 267 | - | - | - | - | - | - | Neurology | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | 4/3: 'Q4 2014 Update complete | - |
| 268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | - | - | 268 | - | - | - | - | - | - | Neurology | - | Time limited endorsement | Full Endorsement | - | - | - | - | - | 4/3: 'Q4 2014 Update complete | 4/3: Testing submitted to NQF on 2/27/2014 |
| - | AAO | ||||||||||||||||||||
| 303 | Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | - | 1536 | 0303 | Percentage of patients aged 18 years and older in sample who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey | Effective Clinical Care | Outcome | AAO | - | - | Surgery Endorsement Maintenance | C - 2015 | - | Full Endorsement | - | - | - | Q2 | Unknown | None | None |
| 304 | Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | - | - | 0304 | Percentage of patients aged 18 years and older in sample who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey | Patient and Caregiver-Centered Experience and Outcomes | Patient Engagement/Experience | AAO | - | - | N/A | - | - | Non-Endorsed/ No Plan to Submit | - | - | - | - | N/A | - | - |
| - | AGA | ||||||||||||||||||||
| 269 | Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented | - | - | 0269 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have documented the disease type, anatomic location and activity, at least once during the reporting period | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| 270 | Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy | - | - | 0270 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have been managed by corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days that have been prescribed corticosteroid sparing therapy in the last reporting year | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| 271 | Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | - | - | 271 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have received dose of corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days and were assessed for risk of bone loss once per the reporting year | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| 272 | Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization | - | - | 272 | Percentage of patients aged 18 years and older with inflammatory bowel disease for whom influenza immunization was recommended, administered or previously received during the reporting year | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| 273 | Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization | - | - | 273 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease that had pneumococcal vaccination administered or previously received | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| 274 | Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | - | - | 274 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease for whom a tuberculosis (TB) screening was performed and results interpreted within six months prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| 275 | Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | - | - | 275 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - AGA Measurment Committee Review | - |
| - | AMA- PCPI | ||||||||||||||||||||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 138v2 | 0028 | 0226 | Percentage of patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user | Community/Population Health | Process | AMA- PCPI | - | - | Behavioral Health | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 008 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 144v2 | 0083 | 0008 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 046 | Medication Reconciliation | - | 0097 | 046 | Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented | Patient Safety | Process | AMA- PCPI | NCQA | - | Care Coordination | B - 2014 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 110 | Preventive Care and Screening: Influenza Immunization | 147v2 | 0041 | 110 | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | Community/Population Health | Process | AMA- PCPI | - | - | Population Health: Prevention | - | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 118 | Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | - | 0066 | 118 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy | Effective Clinical Care | Process | AMA- PCPI | AACF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 197 | Coronary Artery Disease (CAD): Lipid Control | - | 0074 | 197 | Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Correct measure description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result >=100 mg/dL and have a documented plan of care to achieve LDL-C <100mg/dL, including at a minimum the prescription of a statin | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 121 | Adult Kidney Disease: Laboratory Testing (Lipid Profile) | - | 1668 | 121 | Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period | Effective Clinical Care | Process | AMA- PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 122 | Adult Kidney Disease: Blood Pressure Management | - | - | 122 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) and proteinuria with a blood pressure < 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care | Effective Clinical Care | Outcome | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 123 | Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL | - | 1666 | 123 | Percentage of calendar months within a 12-month period during which a hemoglobin level is measured for patients aged 18 years and older with a diagnosis of advanced chronic kidney disease (CKD) (stage 4 or 5, not receiving Renal Replacement Therapy [RRT]) or End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also receiving erythropoiesis-stimulating agent (ESA) therapy have a hemoglobin level > 12.0 g/dL | Effective Clinical Care | Outcome | AMA- PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 039 | Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older | - | 0046 | 039 | Percentage of female patients aged 65 years and older who have a central dual-energy X- ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | - | 0098 | 048 | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | GI/GU | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 173 | Preventive Care and Screening: Unhealthy Alcohol Use – Screening | - | - | 173 | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months | Community/Population Health | Process | AMA- PCPI | - | - | Behavioral Health | - | - | - | - | - | - | - | - | - | Measure replaced by measure NQF #2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling. Measure 2152 endorsed via NQF Behavioral Health project in March 2014 |
| 176 | Rheumatoid Arthritis (RA): Tuberculosis Screening | - | - | 176 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD) | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | - | - | 177 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 178 | Rheumatoid Arthritis (RA): Functional Status Assessment | - | - | 178 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 179 | Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | - | - | 179 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 180 | Rheumatoid Arthritis (RA): Glucocorticoid Management | - | - | 180 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 020 | Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician | - | 0270 | 020 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incision is required) | Patient Safety | Process | AMA- PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | - | - | - | The plan is to retire this measure |
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | - | 0268 | 021 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis | Patient Safety | Process | AMA- PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | '- | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 022 | Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) | - | 0271 | 022 | Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time | Patient Safety | Process | AMA- PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | - | 0239 | 023 | Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Patient Safety | Process | AMA- PCPI | NCQA | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 084 | Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment | - | 0395 | 084 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom quantitative hepatitis C virus (HCV) RNA testing was performed within 12 months prior to initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 085 | Hepatitis C: HCV Genotype Testing Prior to Treatment | - | 0396 | 085 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom hepatitis C virus (HCV) genotype testing was performed within 12 months prior to initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 087 | Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment | - | 0398 | 087 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative hepatitis C virus (HCV) RNA testing was performed between 4-12 weeks after the initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 183 | Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV) | - | 0399 | 183 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A | Community/Population Health | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 005 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 135v2 | 0081 | 005 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 198 | Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment | - | 0079 | 198 | Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior [any time in the past] LVEF assessment is documented within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 006 | Coronary Artery Disease (CAD): Antiplatelet Therapy | - | 0067 | 006 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 197 | Coronary Artery Disease (CAD): Lipid Control | - | 0074 | 197 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at a minimum the prescription of a statin | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 242 | Coronary Artery Disease (CAD): Symptom Management | - | - | 242 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with results of an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 159 | HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed | - | 0404 | 159 | Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | - | 0409 | 205 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 053 | Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting | - | 0047 | 053 | Percentage of patients aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 064 | Asthma: Assessment of Asthma Control – Ambulatory Care Setting | - | 0001 | 064 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk) | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 231 | Asthma: Tobacco Use: Screening - Ambulatory Care Setting | - | - | 231 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma (or their primary caregiver) who were queried about tobacco use and exposure to second hand smoke within their home environment at least once during the one-year measurement period | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 232 | Asthma: Tobacco Use: Intervention - Ambulatory Care Setting | - | - | 232 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma who were identified as tobacco users (or their primary caregiver) who received tobacco cessation intervention at least once during the one-year measurement period | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 051 | Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | - | 0091 | 051 | Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 052 | Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy | - | 0102 | 052 | Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 60% and have symptoms who were prescribed an inhaled bronchodilator | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 276 | Sleep Apnea: Assessment of Sleep Symptoms | - | - | 276 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 277 | Sleep Apnea: Severity Assessment at Initial Diagnosis | - | - | 277 | Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 278 | Sleep Apnea: Positive Airway Pressure Therapy Prescribed | - | - | 278 | Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 279 | Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | - | - | 279 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 280 | Dementia: Staging of Dementia | - | - | 280 | Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 281 | Dementia: Cognitive Assessment | 149v2 | - | 281 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 282 | Dementia: Functional Status Assessment | - | - | 282 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 283 | Dementia: Neuropsychiatric Symptom Assessment | - | - | 283 | Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 284 | Dementia: Management of Neuropsychiatric Symptoms | - | - | 284 | Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 285 | Dementia: Screening for Depressive Symptoms | - | - | 285 | Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 286 | Dementia: Counseling Regarding Safety Concerns | - | - | 286 | Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period | Patient Safety | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 287 | Dementia: Counseling Regarding Risks of Driving | - | - | 287 | Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 288 | Dementia: Caregiver Education and Support | - | - | 288 | Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 133v2 | 0565 | 191 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery | Effective Clinical Care | Outcome | AMA- PCPI | NCQA | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 192 | Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 132v2 | 0564 | 192 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence | Patient Safety | Outcome | AMA- PCPI | NCQA | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 071 | Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer | - | 0387 | 071 | Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | NCCN | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 072 | Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients | - | 0385 | 072 | Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | NCCN | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 143 | Oncology: Medical and Radiation – Pain Intensity Quantified | 157v2 | 0384 | 143 | Percentage of patients, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA- PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 144 | Oncology: Medical and Radiation – Plan of Care for Pain | - | 0383 | 144 | Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA- PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 194 | Oncology: Cancer Stage Documented | - | 0386 | 194 | Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline American Joint Committee on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 359 | Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | - | - | 359 | Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 360 | Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | - | - | 360 | Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study | Patient Safety | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 361 | Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | - | - | 361 | Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements | Patient Safety | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 362 | Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes | - | - | 362 | Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 363 | Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive | - | - | 363 | Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 364 | Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | - | - | 364 | Percentage of final reports for CT imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (eg, follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 007 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 145v2 | 0070 | 007 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta-blocker therapy | Effective Clinical Care | Process | AMA-PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 012 | Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation: | 143v2 | 0086 | 012 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 014 | Age-Related Macular Degeneration (AMD): Dilated Macular Examination | - | 0087 | 014 | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 018 | Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy | 167v2 | 0088 | 018 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 019 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 142v2 | 0089 | 019 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 024 | Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0045 | 024 | Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 028 | Aspirin at Arrival for Acute Myocardial Infarction (AMI) | - | 0092 | 028 | Percentage of patients, regardless of age, with an emergency department discharge diagnosis of acute myocardial infarction (AMI) who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 030 | Perioperative Care: Timing of Prophylactic Antiobiotic—Administering Physician | - | 0269 | 030 | Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures with the indications for prophylactic parenteral antibiotics for whom administration of a prophylactic parenteral antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) | Patient Safety | Process | AMA-PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 031 | Stroke and Stroke Rehabilitation: Venous Thromboembolism (VTE) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage | - | 0240 | 031 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 032 | Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy | - | 0325 | 032 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an antithrombotic at discharge | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 033 | Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at Discharge | - | 0241 | 033 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 035 | Stroke and Stroke Rehabilitation: Screening for Dysphagia | - | 0243 | 035 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 036 | Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered | - | 0244 | 036 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 040 | Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0048 | 040 | Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 041 | Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older | - | 0049 | 041 | Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | NCQA is the steward for this measure |
| 045 | Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardiac Procedures) | - | 0637 | 045 | Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 48 hours of surgical end time | Patient Safety | Process | AMA-PCPI | NCQA | - | Surgery | - | - | Full Endorsement | - | - | - | - | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 047 | Advance Care Plan | - | 0326 | 047 | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Care Coordination | B - 2014 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 049 | Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older | - | 0099 | 049 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | GI/GU | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | - | 0100 | 050 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | NCQA | - | GI/GU | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 054 | Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain | - | 0090 | 054 | Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead electrocardiogram (ECG) performed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 055 | Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope | - | 0093 | 055 | Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead electrocardiogram (ECG) performed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Cardiovascular | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | The PCPI and the American College of Emergency Physicians elected not to submit the measure to NQF for maintenance of endorsement. PQRS data from 2011 suggested a relatively high rate of performance at 96.48% and we felt that the measure would fail to meet the performance gap sub-criterion within the “importance to measure and report” evaluation criterion. However, Syncope is a frequent complaint in the emergency department, accounting for one to three percent of all ED visits and hospital admissions in the US. An ECG remains a critical component of the initial evaluation of a patient presenting with syncope to determine the etiology and institute appropriate treatment strategies. We still collectively support the measure and have plans to maintain it as part of our emergency medicine measure set with no immediate plans for retirement. |
| 056 | Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Vital Signs | - | 0232 | 056 | Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with vital signs documented and reviewed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Pulmonary | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 059 | Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Empiric Antibiotic | - | 0096 | 059 | Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with an appropriate empiric antibiotic prescribed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 067 | Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | - | 0377 | 067 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 068 | Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | - | 0378 | 068 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 069 | Hematology: Multiple Myeloma: Treatment with Bisphosphonates | - | 0380 | 069 | Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 070 | Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | - | 0379 | 070 | Percentage of patients aged 18 years and older seen within a 12 month reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 076 | Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol | - | 0464 | 076 | Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed | Patient Safety | Process | AMA-PCPI | - | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Patient Safety Committee |
| 081 | Adult Kidney Disease: Hemodialysis Adequacy: Solute | - | 0323 | 081 | Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis three times a week for ≥ 90 days who have a spKt/V ≥ 1.2 | Communication and Care Coordination | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 082 | Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute | - | 0321 | 082 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving peritoneal dialysis who have a total Kt/V ≥ 1.7 per week measured once every 4 months | Communication and Care Coordination | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 083 | Hepatitis C: Confirmation of Hepatitis C Viremia | - | 0393 | 083 | Percentage of patients aged 18 years and older who are hepatitis C antibody positive seen for an initial evaluation for whom hepatitis C virus (HCV) RNA testing was ordered or previously performed | Effective Clinical Care | Process | AMA-PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 091 | Acute Otitis Externa (AOE): Topical Therapy | - | 0653 | 091 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations | Effective Clinical Care | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 093 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use: | - | 0654 | 093 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Communication and Care Coordination | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 099 | Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | - | 0391 | 099 | Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade | Effective Clinical Care | Process | AMA-PCPI | CAP | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 100 | Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | - | 0392 | 100 | Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade | Effective Clinical Care | Process | AMA-PCPI | CAP | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 129v3 | 0389 | 102 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer | Efficiency and Cost Reduction | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 104 | Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients | - | 0390 | 104 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist) | Effective Clinical Care | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 106 | Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity | - | 0103 | 106 | Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | AMA-PCPI | - | - | Behavioral Health | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 107 | Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 161v2 | 0104 | 107 | Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | AMA-PCPI | - | - | Behavioral Health | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | Endorsement renewed in 2/14 |
| 109 | Osteoarthritis (OA): Function and Pain Assessment | - | 0050 | 109 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | - | - | Musculoskeletal | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | The American Academy of Orthopedic Surgeons intends to potentially submit this measure for endorsement. The measure lost endorsement because of time and resource constraints that precluded submission of measure for maintenance of endorsement. We continue to support this measure and may plan to resubmit at the next available opportunity. |
| 137 | Melanoma: Continuity of Care – Recall System | - | 0650 | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment | Effective Clinical Care | Structure | AMA-PCPI | NCQA | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 138 | Melanoma: Coordination of Care | - | 0561 | 138 | Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Cancer | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 140 | Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement | - | 0566 | 140 | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 141 | Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | - | 0563 | 141 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 142 | Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications | - | 0051 | 142 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with an assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications | Effective Clinical Care | Process | AMA-PCPI | - | - | Musculoskeletal | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | The American Academy of Orthopedic Surgeons intends to potentially submit this measure for endorsement. The measure lost endorsement because of time and resource constraints that precluded submission of measure for maintenance of endorsement. |
| 145 | Radiology: Exposure Time Reported for Procedures Using Fluoroscopy | - | 0510 | 145 | Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time | Patient Safety | Process | AMA-PCPI | NCQA | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Patient Safety Committee |
| 146 | Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening | - | 0508 | 146 | Percentage of final reports for screening mammograms that are classified as “probably benign” | Efficiency and Cost Reduction | Process | AMA-PCPI | NCQA | - | Efficiency | A -2016 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | - | - | 147 | Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed | Communication and Care Coordination | Structure | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 154 | Falls: Risk Assessment | - | 0101 | 154 | Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months | Patient Safety | Process | AMA-PCPI | NCQA | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 155 | Falls: Plan of Care | - | 0101 | 155 | Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Safety | B - 2014 | - | Time-Limited Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 156 | Oncology: Radiation Dose Limits to Normal Tissues | - | 0382 | 156 | Percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer receiving 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues | Patient Safety | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 185 | Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | - | 0659 | 185 | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | GI/GU | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | Received full endorsement 12/13 |
| 193 | Perioperative Temperature Management | - | 0454 | 193 | Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time | Patient Safety | Process | AMA-PCPI | - | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 195 | Radiology: Stenosis Measurement in Carotid Imaging Reports | - | 0507 | 195 | Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 224 | Melanoma: Overutilization of Imaging Studies in Melanoma | - | 0562 | 224 | Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered | Efficiency and Cost Reduction | Process | AMA-PCPI | NCQA | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 225 | Radiology: Reminder System for Mammograms | - | 0509 | 225 | Percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram | Communication and Care Coordination | Structure | AMA-PCPI | NCQA | - | Efficiency | A -2016 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 245 | Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure | - | - | 245 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique | Effective Clinical Care | Efficiency | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 246 | Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse Measure) | - | - | 246 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings | Effective Clinical Care | Efficiency | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 247 | Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence | - | - | 247 | Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 248 | Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence | - | - | 248 | Percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 320 | Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients: | - | 0658 | 320 | Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Communication and Care Coordination | Process | AMA-PCPI | - | - | GI/GU | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | Received full endorsement 12/13 |
| 325 | Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | - | - | 325 | Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | - | 1525 | 326 | Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism | Patient Safety | Process | AMA-PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 328 | Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/Dl | - | 1667 | 328 | Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL | Effective Clinical Care | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 329 | Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | - | - | 329 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 330 | Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | - | - | 330 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use) | - | - | 331 | Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 7 days of diagnosis or within 10 days after onset of symptoms | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis | - | - | 332 | Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, without clavulante, as a first line antibiotic at the time of diagnosis | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 333 | Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse) | - | - | 333 | Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis | Efficiency and Cost Reduction | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 334 | Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | - | - | 334 | Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis | Effective Clinical Care | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 335 | Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks | - | - | 335 | Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication | Patient Safety | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 336 | Maternity Care: Post-Partum Follow-Up and Care Coordination | - | - | 336 | Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning | Communication and Care Coordination | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 382 | Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 177v2 | 1365 | 382 | Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk | Patient Safety | Process | AMA-PCPI | - | - | Behavioral Health | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| - | APMA | ||||||||||||||||||||
| 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | - | 0417 | 0126 | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months | Effective Clinical Care | Process | APMA | - | - | Endocrine | - | Full Endorsement | Non-Endorsed/ Planned Submission | - | - | - | - | 2014 (scheduled to be resubmitted by June 6, 2014) | This measure was reviewed in the Endocrine review in March 2014. There were issues identified by the committee. The measure was withdrawn for reivew by measure developer and will be revised and resubmitted for June 2014 review. | Working with NQF staff to resolve issues identifed by review committee and then resubmitting for review in June 2014 (submission deadline June 6, 2014) |
| 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | - | 0416 | 0127 | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing | Effective Clinical Care | Process | APMA | - | - | Endocrine | - | Full Endorsement | Non-Endorsed/ Planned Submission | - | - | - | - | 2014 (scheduled to be resubmitted by June 6, 2014) | This measure was reviewed in the Endocrine review in March 2014. There were issues identified by the committee. The measure was withdrawn for reivew by measure developer and will be revised and resubmitted for June 2014 review. | Working with NQF staff to resolve issues identifed by review committee and then resubmitting for review in June 2014 (submission deadline June 6, 2014) |
| - | AQC | ||||||||||||||||||||
| 261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | - | - | 0261 | Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness | Communication and Care Coordination | Process | AQC | - | - | - | - | Not endorsed - not pursing endorsement | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | - | - |
| - | ASBS | ||||||||||||||||||||
| 262 | Image Confirmation of Successful Excision of Image–Localized Breast Lesion | - | - | 0262 | Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy. | Patient Safety | Process | ASBS | - | - | N/A | - | non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | N/A | Measure will be reviewed and any necessary updates will be made by 8/1/2014 | N/A |
| 263 | Preoperative Diagnosis of Breast Cancer | - | - | 0263 | The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method | Effective Clinical Care | Process | ASBS | - | - | N/A | - | non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | N/A | Measure will be reviewed and any necessary updates will be made by 8/1/2014 | N/A |
| 264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer | - | - | 264 | The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure | Effective Clinical Care | Process | ASBS | - | - | N/A | - | non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | N/A | Measure will be reviewed and any necessary updates will be made by 8/1/2014 | N/A |
| - | CAP | ||||||||||||||||||||
| 249 | Barrett's Esophagus | - | - | 0249 | Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia | Effective Clinical Care | Structure | CAP | - | - | Cancer | C - 2015 | - | Full Endorsement | - | - | - | Q4 | TBD | - | Q4 Annual update submitted December 2013 |
| 250 | Radical Prostatectomy Pathology Reporting | - | - | 0250 | Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status | Effective Clinical Care | Structure | CAP | - | - | Cancer | C - 2015 | - | Full Endorsement | - | - | - | Q4 | TBD | - | Q4 Annual update submitted December 2013 |
| 251 | Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | - | - | 251 | This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer | Effective Clinical Care | Structure | CAP | - | - | Cancer | C - 2015 | - | Full Endorsement | - | - | - | Q4 | TBD | - | Q4 Annual update submitted December 2013 |
| - | FOTO | ||||||||||||||||||||
| 217 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments | - | 0422 | 0217 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the knee in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Process | F0T0 | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| 218 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments | - | 0423 | 0218 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the hip in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| 219 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments | - | 0424 | 219 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lower leg, foot or ankle in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| 220 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments | - | 0425 | 220 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lumbar spine in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| 221 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments | - | 0426 | 221 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the shoulder in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| 222 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments | - | 0427 | 222 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the elbow, wrist or hand in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| 223 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments | - | 0428 | 223 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the neck, cranium, mandible, thoracic spine, ribs, or other general orthopedic impairment in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full Endorsement | Full Endorsement | - | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | - |
| - | HRS | ||||||||||||||||||||
| 348 | HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | - | - | 0348 | Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD | Effective Clinical Care | Outcome | HRS | - | - | see column V | - | non-endorsed: Withdrew the measure at NQF’s suggestion from the current cardiac project because both NQF and we felt it was better considered in concert with the hospital-level analysis corollary when that comes up for endorsement maintenance. | Non-Endorsed | - | - | - | - | - | - | Withdrew the measure at NQF’s suggestion from the current cardiac project because both NQF and we felt it was better considered in concert with the hospital-level analysis corollary when that comes up for endorsement maintenance. |
| - | ACCF-AHA | ||||||||||||||||||||
| 243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | - | 0643 | 0243 | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program | Effective Clinical Care | Process | ACCF-AHA | - | - | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | - | 12/21/13 | Measure Testing Completed | Q1 - Submitted for maintenance endorsement 2013 Q4. In-Person meeting scheduled for 4/21-4/22/14 |
| - | MNCM | ||||||||||||||||||||
| 319 | Diabetes Composite: Optimal Diabetes Care | - | 0729 | 0319 | Patients ages 18 through 75 with a diagnosis of diabetes, who meet all the numerator targets of this composite measure: • A1c < 8.0% • LDL < 100 mg/dL • blood pressure < 140/90 mmHg • tobacco non-user and (for patients with a diagnosis of ischemic vascular disease) daily aspirin use unless contraindicated | Effective Clinical Care | Outcome | MNCM | - | - | Endocrine | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 12/1/14 | Cholesterol component changes necessary based on Nov 2013 ACC/AHA new guidelines. | Delayed cycle for meaintence endorsement related to new guidelines |
| 349 | Optimal Vascular Composite | - | 0076 | 0349 | Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use | Effective Clinical Care | Outcome | MNCM | - | - | Cardiovascular | A -2016 | Full Endorsement | Full Endorsement | - | - | - | - | - | Cholesterol component changes necessary based on Nov 2013 ACC/AHA new guidelines. | Annual maintenance completed in April 2013 |
| 370 | Depression Remission at Twelve Months | 159v2 | 0710 | 370 | Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment | Effective Clinical Care | Outcome | MNCM | - | - | Behavioral | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 7/25/14 | - | Annual maintenance completed in April 2013 |
| 371 | Depression Utilization of the PHQ-9 Tool | 160v2 | 0712 | 371 | Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4 month period in which there was a qualifying visit. | Effective Clinical Care | Process | MNCM | - | - | Behavioral | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 7/25/14 | - | Annual maintenance completed in April 2013 |
| - | NCQA | ||||||||||||||||||||
| 066 | Appropriate Testing for Children with Pharyngitis | 146v2 | 0002 | 0066 | Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode | Efficiency and Cost Reduction | Process | NCQA | - | - | HEENT | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 236 | Controlling High Blood Pressure | 165v2 | 0018 | 0236 | Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period. | Effective Clinical Care | Outcome | NCQA | - | - | Cardiovascular | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q1 2013 - Annual update submitted 03/2013 |
| 238 | Use of High-Risk Medications in the Elderly | 156v2 | 0022 | 238 | Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications. | Patient Safety | Process | NCQA | - | - | Patient Safety | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 239 | Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 155v2 | 0024 | 239 | Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity | Community/Population Health | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 310 | Chlamydia Screening for Women | 153v2 | 0033 | 310 | Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period | Community/Population Health | Process | NCQA | - | - | Perinatal & Reproductive Health | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 311 | Use of Appropriate Medications for Asthma | 126v2 | 0036 | 311 | Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Pulmonary/Critical Care | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 240 | Childhood Immunization Status | 117v2 | 0038 | 240 | Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday | Community/Population Health | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 312 | Use of Imaging Studies for Low Back Pain | 166v3 | 0052 | 312 | Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. | Efficiency and Cost Reduction | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Musculoskeletal project. Currently in Public and Member comment phase. | - |
| 065 | Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 154v2 | 0069 | 065 | Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode | Efficiency and Cost Reduction | Process | NCQA | - | - | Infectious Diseases | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | - |
| 366 | ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication | 136v3 | 0108 | 366 | ercentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health Phase III | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Behavioral Health Phase III project beginning in Q3 2014. Initial submission deadline is 7/25/14. | - |
| 001 | Diabetes: Hemoglobin A1c Poor Control | 122v2 | 0059 | 001 | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period | Effective Clinical Care | Outcome | NCQA | - | - | Endocrine Phase I | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Endocrine Phase I project. Currently in Public and Member comment phase. | - |
| 111 | Pneumonia Vaccination Status for Older Adults | 127v2 | 0043 | 111 | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 112 | Breast Cancer Screening | 125v2 | (2372 - New NQF #) | 112 | Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | B - 2014 | Non-Endorsed/Has been submitted for current 2014 project. | Non-Endorsed/Sybmitted Pending Review | - | - | - | - | 2014 | Under maintenance review under the Health & Well-Being project. Currently in Public and Member comment phase. | - |
| 113 | Colorectal Cancer Screening | 130v2 | 0034 | 113 | Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 318 | Falls: Screening for Fall Risk | 139v2 | 0101 | 318 | Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period | Patient Safety | Process | NCQA | - | - | Patient Safety | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 002 | Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL) | 163v2 | 0064 | 002 | Percentage of patients 18–75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dL) during the measurement period | Effective Clinical Care | Outcome | NCQA | - | - | Endocrine Phase III | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Endocrine Phase III project beginning in Q4 2014. Initial submission deadline is 12/5/14. | - |
| 117 | Diabetes: Eye Exam | 131v2 | 0055 | 117 | Percentage of patients 18 through 75 years of age with a diagnosis of diabetes (type 1 and type 2) who had a retinal or dilated eye exam in the measurement period or a negative retinal or dilated eye exam (negative for retinopathy) in the year prior to the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Endocrine Phase I project. Currently in Public and Member comment phase. | - |
| 119 | Diabetes: Medical Attention for Neuropathy | 134v2 | 0062 | 119 | The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Endocrine Phase I project. Currently in Public and Member comment phase. | - |
| 163 | Diabetes: Foot Exam | 123v2 | 0056 | 163 | Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Endocrine Phase I project. Currently in Public and Member comment phase. | - |
| 108 | Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy | - | 0054 | 108 | Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Musculoskeletal project. Currently in Public and Member comment phase. | - |
| 148 | Back Pain: Initial Visit | - | 0322 | 148 | The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who had back pain and function assessed during the initial visit to the clinician for the episode of back pain | Efficiency and Cost Reduction | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Currently open for maintenance review under the Musculoskeletal project. However, NCQA is not seeking NQF re-endorsement for this measure. | - |
| 149 | Back Pain: Physical Exam | - | 0319 | 149 | Percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received a physical examination at the initial visit to the clinician for the episode of back pain | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Currently open for maintenance review under the Musculoskeletal project. However, NCQA is not seeking NQF re-endorsement for this measure. | - |
| 150 | Back Pain: Advice for Normal Activities | - | 0314 | 150 | The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice for normal activities at the initial visit to the clinician for the episode of back pain | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Currently open for maintenance review under the Musculoskeletal project. However, NCQA is not seeking NQF re-endorsement for this measure. | - |
| 151 | Back Pain: Advice Against Bed Rest | - | 0313 | 151 | The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice against bed rest lasting four days or longer at the initial visit to the clinician for the episode of back pain | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Currently open for maintenance review under the Musculoskeletal project. However, NCQA is not seeking NQF re-endorsement for this measure. | - |
| 204 | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 164v2 | 0068 | 204 | Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Cardiovascular | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 236 | Controlling High Blood Pressure | 165v2 | 0018 | 236 | Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period. | Effective Clinical Care | Outcome | NCQA | - | - | Cardiovascular | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q1 2013 - Annual update submitted 03/2013 |
| 241 | Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dL) | 182v3 | 0075 | 241 | Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dL) | Effective Clinical Care | Outcome | NCQA | - | - | Cardiovascular | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 160 | HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | 52v2 | 0405 | 160 | Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis | Effective Clinical Care | Process | NCQA | - | - | Infectious Diseases | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 009 | Anti-Depressant Medication Management | 128v2 | 0105 | 009 | Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months). | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health Phase II | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | - | 2015 | - | Endorsement maintenance was completed on 2/28/14 and endorsement was renewed. |
| 116 | Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use | - | 0058 | 116 | Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode | Efficiency and Cost Reduction | Process | NCQA | - | - | Infectious Diseases | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | - |
| 305 | Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 137v2 | 0004 | 305 | Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 309 | Cervical Cancer Screening | 124v2 | 0032 | 309 | Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q4 | 2015 | - | Q4 2013 - Annual update submitted 12/2013 |
| 365 | Hemoglobin A1c Test for Pediatric Patients | 148v2 | 0060 | 365 | Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Under maintenance review under the Endocrine Phase I project. Currently in Public and Member comment phase. | - |
| 368 | HIV/AIDS: Medical Visit | 62v2 | 0403 | 368 | Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit | Effective Clinical Care | Process | NCQA | - | - | N/A | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | - | This measure went through maintenance review under the Infectious Diseases project back in 2012. The measure was not recommended for re-endorsement. |
| 372 | Maternal Depression Screening | 82v1 | 1401 | 372 | The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child’s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life. | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health Phase III | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Behavioral Health Phase III project beginning in Q3 2014. Initial submission deadline is 7/25/14. | Q1 2013 - Annual update submitted 03/2013 |
| - | Quality Insights of Pennsylvania | ||||||||||||||||||||
| 134 | Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 2v3 | 0418 | 0134 | Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. | Community/Population Health | Process | CMS | - | - | Behavioral Health | A -2016 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2016 | N/A | Q1- Re-Endorsed 2/28/14 |
| 130 | Documentation of Current Medications in the Medical Record | 68v3 | 0419 | 0130 | Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. | Patient Safety | Process | CMS | - | - | Patient Safety | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | Q2 | 2017 | N/A | Q1- No activity |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up | 69v2 | 0421 | 128 | Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥ 18.5 and < 25 | Community/Population Health | Process | CMS | - | - | Health and Well Being | A -2016 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2016 | N/A | Q1 - Annual Update submitted March 2014. CMS is considering changing Comprehensive Review Due Date based on release of new guidelines |
| 378 | Children Who Have Dental Decay or Cavities | 75v2 | - | 378 | Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period | Effective Clinical Care | Process | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | 50v2 | - | 374 | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Communication and Care Coordination | Process | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 377 | Functional Status Assessment for Complex Chronic Conditions | 90v3 | - | 377 | Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments | Patient and Caregiver-Centered Experience and Outcomes | Process | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 22v2 | - | 317 | Percentage of patients aged 18 years and older seen during the measurement period who were screened for high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated | Community/Population Health | Process | CMS | - | - | Cardiovascular | A -2016 | Non-Endorsed | Non-Endorsed/ Planned Submission | - | - | - | Q1 | ? | Measure is being re-tooled by Interagency Workgroup | Q1 - N/A |
| 044 | Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | - | 0236 | 044 | Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision | Effective Clinical Care | Process | CMS | - | - | Surgery | A -2016 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2016 | - | Q1 - N/A |
| 131 | Pain Assessment and Follow-Up | - | 0420 | 131 | Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present | Communication and Care Coordination | Process | CMS | - | - | Health and Well Being | A -2016 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2014 | - | Q1 - measure has been submitted for comprehensive review |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | - | - | 181 | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen | Patient Safety | Process | CMS | - | - | Safety | B - 2014 | Not endorsed | Non-Endorsed/Sybmitted Pending Review | - | - | - | - | 2014 | - | Q1 - measure has been submitted for initial comprehensive reivew. In person meeting April 18th or 19th |
| 182 | Functional Outcome Assessment | - | - | 182 | Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies | Communication and Care Coordination | Process | CMS | - | - | Person and Family Centered Care | C - 2015 | Not endorsed | Non-Endorsed/ Planned Submission | - | - | - | - | - | - | - |
| 228 | Heart Failure (HF): Left Ventricular Function (LVF) Testing | - | - | 228 | Percentage of patients 18 years and older with Left Ventricular Function (LVF) testing documented as being performed within the previous 12 months or LVF testing performed prior to discharge for patients who are hospitalized with a principal diagnosis of Heart Failure (HF) during the reporting period | Effective Clinical Care | Process | CMS | - | - | Cardiovascular | A -2016 | Not endorsed | Non-Endorsed/Sybmitted Pending Review | - | - | - | - | 2014 | - | Q1 - measure has been submitted for comprehensive review |
| 316 | Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting LDL-C | 61v3 & 64v3 | - | 316 | Percentage of patients aged 20 through 79 years whose risk factors* have been assessed and a fasting LDL test has been performed AND percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal. *There are three criteria for this measure based on the patient’s risk category. 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent OR 10-Year Framingham Risk >20% 2. Moderate Level of Risk: Multiple (2+) Risk Factors OR 10-Year Framingham Risk 10-20% 3. Lowest Level of Risk: 0 or 1 Risk Factor OR 10-Year Framingham Risk <10% | Effective Clinical Care | Outcome | CMS | - | - | Cardiovascular | A -2016 | Not endorsed | Non-Endorsed/ Planned Submission | - | - | - | - | - | Measure is being re-tooled by Interagency Workgroup | Q1 - N/A |
| 373 | Hypertension: Improvement in Blood Pressure | 65v3 | - | 373 | Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period. | Effective Clinical Care | Outcome | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 375 | Functional Status Assessment for Knee Replacement | 66v2 | - | 375 | Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments. | Patient and Caregiver-Centered Experience and Outcomes | Process | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 376 | Functional Status Assessment for Hip Replacement | 56v2 | - | 376 | Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments | Patient and Caregiver-Centered Experience and Outcomes | Process | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 379 | Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 74v3 | - | 379 | Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period. | Effective Clinical Care | Process | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 380 | ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range | 179v2 | - | 380 | Average percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR) during the measurement period | Patient Safety | Outcome | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 381 | HIV/AIDS: RNA Control for Patients with HIV | 77v2 | - | 381 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/mL. | Effective Clinical Care | Outcome | CMS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| - | ACCF | ||||||||||||||||||||
| 322 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | - | 670 | 322 | Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period | Efficiency and Cost Reduction | Efficiency | ACC | - | - | Cardiovascular | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | Q2 | 2015 | - | measure maintenance phase |
| 323 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | - | 671 | 323 | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status | Efficiency and Cost Reduction | Efficiency | ACC | - | - | Cardiovascular | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | Q2 | 2015 | - | measure maintenance phase |
| 324 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | - | 672 | 324 | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment | Efficiency and Cost Reduction | Efficiency | ACC | - | - | Cardiovascular | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | Q2 | 2015 | - | measure maintenance phase |
| - | AMA-PCPI | ||||||||||||||||||||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 138v2 | 0028 | 0226 | Percentage of patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user | Community/Population Health | Process | AMA- PCPI | - | - | Behavioral Health | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 008 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 144v2 | 0083 | 0008 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 046 | Medication Reconciliation | - | 0097 | 046 | Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented | Patient Safety | Process | AMA- PCPI | NCQA | - | Care Coordination | B - 2014 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 110 | Preventive Care and Screening: Influenza Immunization | 147v2 | 0041 | 110 | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | Community/Population Health | Process | AMA- PCPI | - | - | Population Health: Prevention | - | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 118 | Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | - | 0066 | 118 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy | Effective Clinical Care | Process | AMA- PCPI | AACF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 197 | Coronary Artery Disease (CAD): Lipid Control | - | 0074 | 197 | Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Correct measure description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result >=100 mg/dL and have a documented plan of care to achieve LDL-C <100mg/dL, including at a minimum the prescription of a statin | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 121 | Adult Kidney Disease: Laboratory Testing (Lipid Profile) | - | 1668 | 121 | Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period | Effective Clinical Care | Process | AMA- PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 122 | Adult Kidney Disease: Blood Pressure Management | - | - | 122 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) and proteinuria with a blood pressure < 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care | Effective Clinical Care | Outcome | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 123 | Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL | - | 1666 | 123 | Percentage of calendar months within a 12-month period during which a hemoglobin level is measured for patients aged 18 years and older with a diagnosis of advanced chronic kidney disease (CKD) (stage 4 or 5, not receiving Renal Replacement Therapy [RRT]) or End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also receiving erythropoiesis-stimulating agent (ESA) therapy have a hemoglobin level > 12.0 g/dL | Effective Clinical Care | Outcome | AMA- PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 039 | Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older | - | 0046 | 039 | Percentage of female patients aged 65 years and older who have a central dual-energy X- ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | - | 0098 | 048 | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | GI/GU | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 173 | Preventive Care and Screening: Unhealthy Alcohol Use – Screening | - | - | 173 | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months | Community/Population Health | Process | AMA- PCPI | - | - | Behavioral Health | - | - | - | - | - | - | - | - | - | Measure replaced by measure NQF #2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling. Measure 2152 endorsed via NQF Behavioral Health project in March 2014 |
| 176 | Rheumatoid Arthritis (RA): Tuberculosis Screening | - | - | 176 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD) | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | - | - | 177 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 178 | Rheumatoid Arthritis (RA): Functional Status Assessment | - | - | 178 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 179 | Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | - | - | 179 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 180 | Rheumatoid Arthritis (RA): Glucocorticoid Management | - | - | 180 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 020 | Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician | - | 0270 | 020 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incision is required) | Patient Safety | Process | AMA- PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | - | - | - | The plan is to retire this measure |
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | - | 0268 | 021 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis | Patient Safety | Process | AMA- PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | '- | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 022 | Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) | - | 0271 | 022 | Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time | Patient Safety | Process | AMA- PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | - | 0239 | 023 | Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Patient Safety | Process | AMA- PCPI | NCQA | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 084 | Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment | - | 0395 | 084 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom quantitative hepatitis C virus (HCV) RNA testing was performed within 12 months prior to initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 085 | Hepatitis C: HCV Genotype Testing Prior to Treatment | - | 0396 | 085 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom hepatitis C virus (HCV) genotype testing was performed within 12 months prior to initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 087 | Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment | - | 0398 | 087 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative hepatitis C virus (HCV) RNA testing was performed between 4-12 weeks after the initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 183 | Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV) | - | 0399 | 183 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A | Community/Population Health | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 005 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 135v2 | 0081 | 005 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 198 | Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment | - | 0079 | 198 | Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior [any time in the past] LVEF assessment is documented within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 006 | Coronary Artery Disease (CAD): Antiplatelet Therapy | - | 0067 | 006 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 197 | Coronary Artery Disease (CAD): Lipid Control | - | 0074 | 197 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at a minimum the prescription of a statin | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 242 | Coronary Artery Disease (CAD): Symptom Management | - | - | 242 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with results of an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 159 | HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed | - | 0404 | 159 | Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | - | 0409 | 205 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 053 | Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting | - | 0047 | 053 | Percentage of patients aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 064 | Asthma: Assessment of Asthma Control – Ambulatory Care Setting | - | 0001 | 064 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk) | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 231 | Asthma: Tobacco Use: Screening - Ambulatory Care Setting | - | - | 231 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma (or their primary caregiver) who were queried about tobacco use and exposure to second hand smoke within their home environment at least once during the one-year measurement period | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 232 | Asthma: Tobacco Use: Intervention - Ambulatory Care Setting | - | - | 232 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma who were identified as tobacco users (or their primary caregiver) who received tobacco cessation intervention at least once during the one-year measurement period | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 051 | Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | - | 0091 | 051 | Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 052 | Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy | - | 0102 | 052 | Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 60% and have symptoms who were prescribed an inhaled bronchodilator | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 276 | Sleep Apnea: Assessment of Sleep Symptoms | - | - | 276 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 277 | Sleep Apnea: Severity Assessment at Initial Diagnosis | - | - | 277 | Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 278 | Sleep Apnea: Positive Airway Pressure Therapy Prescribed | - | - | 278 | Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 279 | Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | - | - | 279 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 280 | Dementia: Staging of Dementia | - | - | 280 | Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 281 | Dementia: Cognitive Assessment | 149v2 | - | 281 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 282 | Dementia: Functional Status Assessment | - | - | 282 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 283 | Dementia: Neuropsychiatric Symptom Assessment | - | - | 283 | Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 284 | Dementia: Management of Neuropsychiatric Symptoms | - | - | 284 | Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 285 | Dementia: Screening for Depressive Symptoms | - | - | 285 | Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 286 | Dementia: Counseling Regarding Safety Concerns | - | - | 286 | Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period | Patient Safety | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 287 | Dementia: Counseling Regarding Risks of Driving | - | - | 287 | Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 288 | Dementia: Caregiver Education and Support | - | - | 288 | Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 133v2 | 0565 | 191 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery | Effective Clinical Care | Outcome | AMA- PCPI | NCQA | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 192 | Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 132v2 | 0564 | 192 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence | Patient Safety | Outcome | AMA- PCPI | NCQA | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 071 | Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer | - | 0387 | 071 | Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | NCCN | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 072 | Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients | - | 0385 | 072 | Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | NCCN | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 143 | Oncology: Medical and Radiation – Pain Intensity Quantified | 157v2 | 0384 | 143 | Percentage of patients, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA- PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 144 | Oncology: Medical and Radiation – Plan of Care for Pain | - | 0383 | 144 | Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA- PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 194 | Oncology: Cancer Stage Documented | - | 0386 | 194 | Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline American Joint Committee on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 359 | Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | - | - | 359 | Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 360 | Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | - | - | 360 | Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study | Patient Safety | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 361 | Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | - | - | 361 | Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements | Patient Safety | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 362 | Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes | - | - | 362 | Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 363 | Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive | - | - | 363 | Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 364 | Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | - | - | 364 | Percentage of final reports for CT imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (eg, follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 007 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 145v2 | 0070 | 007 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta-blocker therapy | Effective Clinical Care | Process | AMA-PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 012 | Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation: | 143v2 | 0086 | 012 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 014 | Age-Related Macular Degeneration (AMD): Dilated Macular Examination | - | 0087 | 014 | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 018 | Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy | 167v2 | 0088 | 018 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 019 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 142v2 | 0089 | 019 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 024 | Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0045 | 024 | Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 028 | Aspirin at Arrival for Acute Myocardial Infarction (AMI) | - | 0092 | 028 | Percentage of patients, regardless of age, with an emergency department discharge diagnosis of acute myocardial infarction (AMI) who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 030 | Perioperative Care: Timing of Prophylactic Antiobiotic—Administering Physician | - | 0269 | 030 | Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures with the indications for prophylactic parenteral antibiotics for whom administration of a prophylactic parenteral antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) | Patient Safety | Process | AMA-PCPI | NCQA | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 031 | Stroke and Stroke Rehabilitation: Venous Thromboembolism (VTE) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage | - | 0240 | 031 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 032 | Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy | - | 0325 | 032 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an antithrombotic at discharge | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 033 | Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at Discharge | - | 0241 | 033 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 035 | Stroke and Stroke Rehabilitation: Screening for Dysphagia | - | 0243 | 035 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 036 | Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered | - | 0244 | 036 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 040 | Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0048 | 040 | Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 041 | Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older | - | 0049 | 041 | Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | NCQA is the steward for this measure |
| 045 | Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardiac Procedures) | - | 0637 | 045 | Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 48 hours of surgical end time | Patient Safety | Process | AMA-PCPI | NCQA | - | Surgery | - | - | Full Endorsement | - | - | - | - | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 047 | Advance Care Plan | - | 0326 | 047 | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Care Coordination | B - 2014 | - | Full Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 049 | Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older | - | 0099 | 049 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | GI/GU | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | - | 0100 | 050 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | NCQA | - | GI/GU | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 054 | Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain | - | 0090 | 054 | Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead electrocardiogram (ECG) performed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 055 | Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope | - | 0093 | 055 | Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead electrocardiogram (ECG) performed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Cardiovascular | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | The PCPI and the American College of Emergency Physicians elected not to submit the measure to NQF for maintenance of endorsement. PQRS data from 2011 suggested a relatively high rate of performance at 96.48% and we felt that the measure would fail to meet the performance gap sub-criterion within the “importance to measure and report” evaluation criterion. However, Syncope is a frequent complaint in the emergency department, accounting for one to three percent of all ED visits and hospital admissions in the US. An ECG remains a critical component of the initial evaluation of a patient presenting with syncope to determine the etiology and institute appropriate treatment strategies. We still collectively support the measure and have plans to maintain it as part of our emergency medicine measure set with no immediate plans for retirement. |
| 056 | Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Vital Signs | - | 0232 | 056 | Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with vital signs documented and reviewed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Pulmonary | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 059 | Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Empiric Antibiotic | - | 0096 | 059 | Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with an appropriate empiric antibiotic prescribed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Pulmonary | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 067 | Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | - | 0377 | 067 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 068 | Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | - | 0378 | 068 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 069 | Hematology: Multiple Myeloma: Treatment with Bisphosphonates | - | 0380 | 069 | Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 070 | Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | - | 0379 | 070 | Percentage of patients aged 18 years and older seen within a 12 month reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 076 | Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol | - | 0464 | 076 | Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed | Patient Safety | Process | AMA-PCPI | - | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Patient Safety Committee |
| 081 | Adult Kidney Disease: Hemodialysis Adequacy: Solute | - | 0323 | 081 | Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis three times a week for ≥ 90 days who have a spKt/V ≥ 1.2 | Communication and Care Coordination | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 082 | Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute | - | 0321 | 082 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving peritoneal dialysis who have a total Kt/V ≥ 1.7 per week measured once every 4 months | Communication and Care Coordination | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 083 | Hepatitis C: Confirmation of Hepatitis C Viremia | - | 0393 | 083 | Percentage of patients aged 18 years and older who are hepatitis C antibody positive seen for an initial evaluation for whom hepatitis C virus (HCV) RNA testing was ordered or previously performed | Effective Clinical Care | Process | AMA-PCPI | - | - | Infectious disease | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 091 | Acute Otitis Externa (AOE): Topical Therapy | - | 0653 | 091 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations | Effective Clinical Care | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 093 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use: | - | 0654 | 093 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Communication and Care Coordination | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 099 | Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | - | 0391 | 099 | Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade | Effective Clinical Care | Process | AMA-PCPI | CAP | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 100 | Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | - | 0392 | 100 | Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade | Effective Clinical Care | Process | AMA-PCPI | CAP | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 129v3 | 0389 | 102 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer | Efficiency and Cost Reduction | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 104 | Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients | - | 0390 | 104 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist) | Effective Clinical Care | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 106 | Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity | - | 0103 | 106 | Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | AMA-PCPI | - | - | Behavioral Health | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 107 | Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 161v2 | 0104 | 107 | Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | AMA-PCPI | - | - | Behavioral Health | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | Endorsement renewed in 2/14 |
| 109 | Osteoarthritis (OA): Function and Pain Assessment | - | 0050 | 109 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | - | - | Musculoskeletal | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | The American Academy of Orthopedic Surgeons intends to potentially submit this measure for endorsement. The measure lost endorsement because of time and resource constraints that precluded submission of measure for maintenance of endorsement. We continue to support this measure and may plan to resubmit at the next available opportunity. |
| 137 | Melanoma: Continuity of Care – Recall System | - | 0650 | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment | Effective Clinical Care | Structure | AMA-PCPI | NCQA | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 138 | Melanoma: Coordination of Care | - | 0561 | 138 | Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Cancer | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 140 | Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement | - | 0566 | 140 | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Time-Limited Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 141 | Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | - | 0563 | 141 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | HEENT | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 142 | Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications | - | 0051 | 142 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with an assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications | Effective Clinical Care | Process | AMA-PCPI | - | - | Musculoskeletal | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | The American Academy of Orthopedic Surgeons intends to potentially submit this measure for endorsement. The measure lost endorsement because of time and resource constraints that precluded submission of measure for maintenance of endorsement. |
| 145 | Radiology: Exposure Time Reported for Procedures Using Fluoroscopy | - | 0510 | 145 | Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time | Patient Safety | Process | AMA-PCPI | NCQA | - | Safety | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Patient Safety Committee |
| 146 | Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening | - | 0508 | 146 | Percentage of final reports for screening mammograms that are classified as “probably benign” | Efficiency and Cost Reduction | Process | AMA-PCPI | NCQA | - | Efficiency | A -2016 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | - | - | 147 | Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed | Communication and Care Coordination | Structure | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 154 | Falls: Risk Assessment | - | 0101 | 154 | Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months | Patient Safety | Process | AMA-PCPI | NCQA | - | Safety | B - 2014 | - | Time-Limited Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 155 | Falls: Plan of Care | - | 0101 | 155 | Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Safety | B - 2014 | - | Time-Limited Endorsement | - | - | - | - | - | - | NCQA is the steward for this measure |
| 156 | Oncology: Radiation Dose Limits to Normal Tissues | - | 0382 | 156 | Percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer receiving 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues | Patient Safety | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 185 | Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | - | 0659 | 185 | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | GI/GU | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | Received full endorsement 12/13 |
| 193 | Perioperative Temperature Management | - | 0454 | 193 | Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time | Patient Safety | Process | AMA-PCPI | - | - | Surgery | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQF's Surgery Committee |
| 195 | Radiology: Stenosis Measurement in Carotid Imaging Reports | - | 0507 | 195 | Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Neurology | C - 2015 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 224 | Melanoma: Overutilization of Imaging Studies in Melanoma | - | 0562 | 224 | Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered | Efficiency and Cost Reduction | Process | AMA-PCPI | NCQA | - | Cancer | B - 2014 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 225 | Radiology: Reminder System for Mammograms | - | 0509 | 225 | Percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram | Communication and Care Coordination | Structure | AMA-PCPI | NCQA | - | Efficiency | A -2016 | - | Full Endorsement | - | - | - | Q3 | TBD by NQF | - | - |
| 245 | Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure | - | - | 245 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique | Effective Clinical Care | Efficiency | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 246 | Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse Measure) | - | - | 246 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings | Effective Clinical Care | Efficiency | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 247 | Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence | - | - | 247 | Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 248 | Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence | - | - | 248 | Percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 320 | Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients: | - | 0658 | 320 | Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Communication and Care Coordination | Process | AMA-PCPI | - | - | GI/GU | C - 2015 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | Received full endorsement 12/13 |
| 325 | Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | - | - | 325 | Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | - | 1525 | 326 | Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism | Patient Safety | Process | AMA-PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full Endorsement | - | - | - | TBD by NQF | TBD by NQF | - | - |
| 328 | Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/Dl | - | 1667 | 328 | Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL | Effective Clinical Care | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full Endorsement | - | - | - | Q2 | TBD by NQF | - | - |
| 329 | Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | - | - | 329 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 330 | Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | - | - | 330 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use) | - | - | 331 | Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 7 days of diagnosis or within 10 days after onset of symptoms | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis | - | - | 332 | Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, without clavulante, as a first line antibiotic at the time of diagnosis | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 333 | Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse) | - | - | 333 | Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis | Efficiency and Cost Reduction | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 334 | Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | - | - | 334 | Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis | Effective Clinical Care | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| 335 | Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks | - | - | 335 | Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication | Patient Safety | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | TBD by NQF | - | - |
| - | HRSA | ||||||||||||||||||||
| 338 | HIV Viral Load Suppression | - | 2082 | 0338 | The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year | Effective Clinical Care | Outcome | HRSA | - | - | Infectious Disease | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | - | eMeasure in progress | annual update submitted |
| 339 | Prescription of HIV Antiretroviral Therapy | - | 2083 | 0339 | Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year | Effective Clinical Care | Process | HRSA | - | - | Infectious Disease | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | - | eMeasure in progress | annual update submitted |
| 340 | HIV Medical Visit Frequency | - | 2079 | 340 | Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits | Efficiency and Cost Reduction | Process | HRSA | - | - | Infectious Disease | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | - | eMeasure in progress | annual update submitted |
| 341 | Gap in HIV Medical Visits | - | 2080 | 341 | Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months | Efficiency and Cost Reduction | Process | HRSA | - | - | Infectious Disease | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | - | eMeasure in progress | annual update submitted |
| - | AAD | ||||||||||||||||||||
| 265 | Biopsy Follow-Up | - | - | 0265 | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician | Communication and Care Coordination | Process | AAD | - | - | - | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 337 | Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier | - | - | 0337 | Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test | Effective Clinical Care | Process | AAD | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q1 - Measure Testing planned for beginning Summer 2104, and then to be submitted for NQF endorsement | - |
| 137 | Melanoma: Continuity of Care | - | 0650 | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered at least once within a 12-month period into a recall system that includes: A target date for the next complete physical skin exam, & - A process to follow up with patients who either did not make an appointment within the specified time frame or who missed a scheduled appointment | Effective Clinical Care | Process | AAD | - | - | Cancer Project | C - 2015 | - | Full Endorsement | - | - | - | - | 2015 | Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall 2014 | Measure Maintainance planned for second half of 2014, Planned submission for re-esndorsement in 2015 |
| 224 | Melanoma: Overutilization of Imaging Studies | - | 0562 | 224 | Percentage of patients with melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered. | Efficient Use of Healthcare Resources/Affordable Care | Process | AAD | - | - | Cancer Project | C - 2015 | - | Full Endorsement | - | - | - | - | 2015 | Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall 2014 | Measure Maintainance planned for second half of 2014, Planned submission for re-esndorsement in 2015 |
| 138 | Melanoma: Coordination of Care | - | - | 138 | Percentage of patient visits, regardless of patient age, with a new occurrence of melanoma. They must have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis. | Care Coordination | Process | AAD | - | - | - | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| - | ACEP | ||||||||||||||||||||
| 254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | - | 0651 | 0254 | Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location | Effective Clinical Care | Process | ACEP | - | - | To Be Determined | - | - | Time-Limited Endorsement | - | - | - | - | - | Test Results worksheet that we received from NQF was drafted in Q1 of 2014. The test results are currently undergoing final review, and we expect to upload and submit them to the NQF portal within the next two weeks | - |
| 255 | Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | - | 0652 | 0255 | Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED) | Effective Clinical Care | Process | ACEP | - | - | To Be Determined | - | - | Time-Limited Endorsement | - | - | - | - | - | - | - |
| - | AMA-PCPI/NCQA | ||||||||||||||||||||
| 046 | Medication Reconciliation | - | 0097 | 046 | Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented | Patient Safety | Process | AMA- PCPI | NCQA | - | Patient Safety | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 039 | Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older | - | 0046 | 039 | Percentage of female patients aged 65 years and older who have a central dual-energy X- ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | - |
| 048 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | - | 0098 | 048 | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | N/A | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 159 | HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed | - | 0404 | 159 | Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | - | 0409 | 205 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 024 | Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0045 | 024 | Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | - |
| 040 | Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0048 | 040 | Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | - |
| 041 | Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older | - | 0049 | 041 | Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full Endorsement | Full Endorsement | - | - | - | - | 2014 | Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | - |
| 047 | Advance Care Plan | - | 0326 | 047 | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Care Coordination | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 049 | Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older | - | 0099 | 049 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | N/A | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 050 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | - | 0100 | 050 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | NCQA | - | N/A | - | - | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | - | - |
| 154 | Falls: Risk Assessment | - | 0101 | 154 | Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months | Patient Safety | Process | AMA-PCPI | NCQA | - | Patient Safety | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| 155 | Falls: Plan of Care | - | 0101 | 155 | Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Patient Safety | C - 2015 | Full Endorsement | Full Endorsement | - | - | - | Q1 | 2015 | - | Q1 2014 - Annual update submitted 03/2014 |
| - | SVS | ||||||||||||||||||||
| 172 | Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula | - | 0259 | 0172 | Percentage of patients aged 18 years and older with a diagnosis of advanced Chronic Kidney Disease (CKD) (stage 3, 4 or 5) or End Stage Renal Disease (ESRD) requiring hemodialysis vascular access documented by surgeon to have received autogenous AV fistula | Effective Clinical Care | Process | SVS | - | - | NA | - | Not Endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | NA | NA | Measure was not re-endorsed by NQF upon maintenance review during the 2011 maintenance cycle. No current plans for re-submission. |
| 257 | Statin Therapy at Discharge after Lower Extremity Bypass (LEB) | - | 1519 | 0257 | Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge | Effective Clinical Care | Process | SVS | - | - | Surgery | A -2016 | Full-Endorsement 2012 | Full Endorsement | - | - | - | Q1 | Unknown | NA | None. |
| 258 | Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7 | - | - | 258 | Percent of patients undergoing open repair of small or moderate sized non-ruptured abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) | Communication and Care Coordination | Outcome | SVS | - | - | NA | - | Not Endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | NA | NA | No current plans for submission. |
| 259 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) | - | - | 259 | Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) | Communication and Care Coordination | Outcome | SVS | - | - | NA | - | Not Endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | NA | NA | No current plans for submission. |
| 260 | Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | - | - | 260 | Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 | Communication and Care Coordination | Process | SVS | - | - | NA | - | Not Endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | NA | NA | No current plans for submission. |
| 344 | Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | - | - | 344 | Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 | Effective Clinical Care | Outcome | svs | - | - | NA | - | Not Endorsed | Non-Endorsed/ No Plan to Submit | - | - | - | - | NA | NA | No current plans for submission. |
| 345 | Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) | - | - | 345 | Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital | Effective Clinical Care | Outcome | SVS | - | - | Surgery | A -2016 | Full-Endorsement 2012 | Full Endorsement | - | - | - | Q1 | Unknown | NA | None. |
| 346 | Rate of Postoperative Stroke or Death in Asymptomatic Patients undergoing Carotid Endarterectomy (CEA) | - | - | 346 | Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital | Effective Clinical Care | Outcome | SVS | - | - | Surgery | A -2016 | Full-Endorsement 2012 | Full Endorsement | - | - | - | Q1 | Unknown | NA | None. |
| 347 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital | - | - | 347 | Percent of patients undergoing endovascular repair of small or moderate abdominal aortic aneurysms (AAA) who die while in the hospital | Effective Clinical Care | Outcome | svs | - | - | Surgery | A -2016 | Full-Endorsement 2012 | Full Endorsement | - | - | - | - | Unknown | NA | None. |
NQF_Q2 2014 Status
| PQRS Number | Measure Title | Measure Number | Measure Description | NQS Domain | Measure Type | Measure Developer/Steward | NQF Project Committee | NQF Cycle | NQF Endorsement Status | Annual Update Due Date | Comprehensive Review Due Date | Additional information (e.g., Testing Results, Revisions), including Month/Year Completed or Anticipated | Synopsis of NQF Endorsement Activity and/or NQF Communications since the most Recent Quarterly Update | ||||||||
| CMS | NQF | PQRS | #1 | #2 | #3 | Q2 2013 | Q1 2014 | Q2 2014 | Q3 2014 | Q4 2014 | |||||||||||
| - | AAD | ||||||||||||||||||||
| 265 | Biopsy Follow-Up | - | - | 265 | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician | Communication and Care Coordination | Process | AAD | - | - | - | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/Lost Endorsement | - | - | - | - | - | No changes |
| 337 | Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier | - | - | 337 | Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test | Effective Clinical Care | Process | AAD | - | - | - | - | - | Non-Endorsed/Planned Submission | Non-Endorsed/Planned Submission | - | - | - | - | Q1 - Measure Testing planned for Summer/Fall 2014, and then to be submitted for NQF endorsement | No changes |
| 137 | Melanoma: Continuity of Care | - | 0650 | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered at least once within a 12-month period into a recall system that includes: A target date for the next complete physical skin exam, & - A process to follow up with patients who either did not make an appointment within the specified time frame or who missed a scheduled appointment | Effective Clinical Care | Process | AAD | - | - | Cancer Project | C - 2015 | - | Full | Full | - | - | TBD by NQF | 2015 | Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall 2014 | No Changes |
| 224 | Melanoma: Overutilization of Imaging Studies | - | 0562 | 224 | Percentage of patients with melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered. | Efficient Use of Healthcare Resources/Affordable Care | Process | AAD | - | - | Cancer Project | C - 2015 | - | Full | Full | - | - | TBD by NQF | 2015 | Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall 2014 | No Changes |
| 138 | Melanoma: Coordination of Care | - | - | 138 | Percentage of patient visits, regardless of patient age, with a new occurrence of melanoma. They must have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis. | Care Coordination | Process | AAD | - | - | - | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/Lost Endorsement | - | - | - | - | - | No Changes |
| - | AAHKS | ||||||||||||||||||||
| 351 | Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | - | - | 351 | Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of Deep Vein Thrombosis, Pulmonary Embolism, Myocardial Infarction, Arrhythmia and Stroke | Patient Safety | Process | AAHKS | - | - | AAHKS is a small specialty society with limited staff and resources. Due to the burdensome process of NQF measure endorsement, AAHKS is not currently capable of seeking NQF endorsement. (04/07/14) | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | N/A |
| 352 | Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | - | - | 352 | Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet | Patient Safety | Process | AAHKS | - | - | - | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | N/A |
| 353 | Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | - | - | 353 | Percentage of patients regardless of age or gender undergoing total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of prosthetic implant | Patient Safety | Process | AAHKS | - | - | - | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | N/A |
| 350 | Total Knee Replacement: Shared Decision- Making: Trial of Conservative (Non-surgical) Therapy (04/07/14) | - | - | 350 | Percentange of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy prior to the procedure | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| - | AAN | ||||||||||||||||||||
| 289 | Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review | - | - | 289 | All patients with a diagnosis of Parkinson’s disease who had an annual assessment including a review of current medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at least annually | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | Q1 - no changes Q2 - no changes |
| 290 | Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment | - | - | 290 | All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric disorders or disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at least annually | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | Q1 - no changes Q2 - no changes |
| 291 | Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment | - | - | 291 | All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction at least annually | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | Q1 - no changes Q2 - no changes |
| 292 | Parkinson’s Disease: Querying about Sleep Disturbances | - | - | 292 | All patients with a diagnosis of Parkinson’s disease (or caregivers, as appropriate) who were queried about sleep disturbances at least annually | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | Q1 - no changes Q2 - no changes |
| 293 | Parkinson’s Disease: Rehabilitative Therapy Options | - | - | 293 | All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed at least annually | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | 4/3: Q2 2014 Update/revision to be initiated | Q1 - no changes Q2 - no changes |
| 294 | Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed | - | - | 294 | All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | 4/3: Q2 '2014 Update/revision to be initiated | Q1 - no changes Q2 - no changes |
| 266 | Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies) | - | - | 266 | Percentage of patient visits with a diagnosis of epilepsy who had the type(s) of seizure(s) and current seizure frequency(ies) for each seizure type documented in the medical record | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | Measure set is current;y undergoing an update and we plan to have updated measures in the fourth quarter of 2014. | Q1 - no changes Q2 - no changes |
| 267 | Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome | - | - | 267 | All visits for patients with a diagnosis of epilepsy who had their etiology of epilepsy or with epilepsy syndrome(s) reviewed and documented if known, or documented as unknown or cryptogenic | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Non-endorsed | Non-Endorsed/No Plan to Submit | Non-Endorsed | - | - | - | - | Measure set is current;y undergoing an update and we plan to have updated measures in the fourth quarter of 2014. | Q1 - no changes Q2 - no changes |
| 268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | - | - | 268 | All female patients of childbearing potential (12-44 years old) diagnosed with epilepsy who were counseled about epilepsy and how its treatment may affect contraception and pregnancy at least once a year | Effective Clinical Care | Process | AAN | - | - | Neurology | - | Time limited endorsement | Time-Limited | Full Endorsement | - | - | - | - | Measure set is current;y undergoing an update and we plan to have updated measures in the fourth quarter of 2014. | 4/3: Testing submitted to NQF on 2/27/2014 NQF Endorsed on 4/8/2014 Q2 - no update |
| - | AAO | ||||||||||||||||||||
| 303 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 304 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 140 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 141 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 14 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| - | ABIM | ||||||||||||||||||||
| 295 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 296 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 297 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 298 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 299 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 300 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 301 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 302 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| - | ACC | ||||||||||||||||||||
| 322 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | - | 0670 | 322 | Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period | Efficiency and Cost Reduction | Efficiency | ACC | - | - | Cardiovascular | B - 2014 | Full | Full | Full Endorsement | - | - | Q2 | 2015 | - | Q1 - No Update Q2 - No Update |
| 323 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | - | 0671 | 323 | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status | Efficiency and Cost Reduction | Efficiency | ACC | - | - | Cardiovascular | B - 2014 | Full | Full | Full Endorsement | - | - | Q2 | 2015 | - | Q1 - No Update Q2 - No Update |
| 324 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | - | 0672 | 324 | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment | Efficiency and Cost Reduction | Efficiency | ACC | - | - | Cardiovascular | B - 2014 | Full | Full | Full Endorsement | - | - | Q2 | 2015 | - | Q1 - No Update Q2 - No Update |
| - | ACCF-AHA | ||||||||||||||||||||
| 243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | - | 0643 | 243 | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program | Effective Clinical Care | Process | ACCF-AHA | - | - | Cardiovascular | A -2016 | Submission for NQF endorsement in Q4 of 2013 | Non-Endorsed/Sybmitted Pending Review | Non-Endorsed/Submitted Pending Review | - | - | - | 12/21/13 | Measure Testing Completed | Q1 - Submitted for maintenance endorsement 2013 Q4. Q2- In-Person meeting scheduled for 4/21-4/22/14; NQF suggests making modifications and re-voting Q3- Recommended for endorsement by NQF steering committee in early July 2014. |
| - | ACEP | ||||||||||||||||||||
| 254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | - | 0651 | 254 | Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location | Effective Clinical Care | Process | ACEP | - | - | To Be Determined | - | - | Time-Limited | Time-Limited | - | - | - | - | Test Results worksheet that we received from NQF was drafted in Q1 of 2014. The test results are currently undergoing final review, and we expect to upload and submit them to the NQF portal within the next two weeks | Test results submitted on 6/23 |
| 255 | Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | - | 0652 | 255 | Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED) | Effective Clinical Care | Process | ACEP | - | - | To Be Determined | - | - | Time-Limited | Time-Limited | - | - | - | - | ACEP will not be submitting test results for this measure | This mesaure may be de-endorsed by NQF |
| - | ACS | ||||||||||||||||||||
| 354 | Anastomotic Leak Intervention | - | - | 354 | Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery | Effective Clinical Care | Outcome | ACS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 355 | Unplanned Reoperation within the 30 Day Postoperative Period | - | - | 355 | Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period | Effective Clinical Care | Outcome | ACS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure | - | - | 356 | Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure | Effective Clinical Care | Outcome | ACS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 357 | Surgical Site Infection (SSI) | - | - | 357 | Percentage of patients aged 18 years and older who had a surgical site infection (SSI) | Effective Clinical Care | Outcome | ACS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 358 | Patient-Centered Surgical Risk Assessment and Communication | - | - | 358 | Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon | Patient and Caregiver-Centered Experience and Outcomes | Process | ACS | - | - | - | - | - | - | - | - | - | - | - | - | - |
| - | AGA | ||||||||||||||||||||
| 269 | Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented | - | - | 269 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have documented the disease type, anatomic location and activity, at least once during the reporting period | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| 270 | Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy | - | - | 270 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have been managed by corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days that have been prescribed corticosteroid sparing therapy in the last reporting year | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| 271 | Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | - | - | 271 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have received dose of corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days and were assessed for risk of bone loss once per the reporting year | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| 272 | Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization | - | - | 272 | Percentage of patients aged 18 years and older with inflammatory bowel disease for whom influenza immunization was recommended, administered or previously received during the reporting year | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| 273 | Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization | - | - | 273 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease that had pneumococcal vaccination administered or previously received | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| 274 | Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | - | - | 274 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease for whom a tuberculosis (TB) screening was performed and results interpreted within six months prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| 275 | Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | - | - | 275 | Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy | Effective Clinical Care | Process | AGA | - | - | TBD | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | - | Q1 - AGA Measurment Committee Review Q2-Reviewed by AGA Measures Committee, updated measures group. Planned comprehensive review during 2014 by AGA Quality Measures Committee. | - |
| - | AHA | ||||||||||||||||||||
| 187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy | - | N/A | 187 | Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well | Effective Clinical Care | Outcome | AHA | ASA | TJC | Neurology | C - 2015 | Non_Endorsed/ We have not been able to get sufficient users for this measure from the AHA/ASA Get With The Guidelines Stroke Registry. When we do we will submit. So for next few cells put no plan to submit unless we get enough data to meet NQF validity testing requirements | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | Q2-No Change | Per earlier communication we will only submit to NQF once we have sufficient data to do meet the validty requiremenst of NQF-Q2 no Changes |
| - | AMA | ||||||||||||||||||||
| 327 | Pediatric Kidney Disease: Adequacy of Volume Management: | - | - | 327 | Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist | Effective Clinical Care | Process | '- | - | - | Renal | B - 2014 | Non-Endorsed/Planned Submission | Non-Endorsed/Planned Submission | TBD by NQF | Q2 - No changes | |||||
| - | AMA- PCPI | ||||||||||||||||||||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 138v2 | 0028 | 226 | Percentage of patients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user | Community/Population Health | Process | AMA- PCPI | - | - | Behavioral Health | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 – no changes |
| 8 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 144v2 | 0083 | 008 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 110 | Preventive Care and Screening: Influenza Immunization | 147v2 | 0041 | 110 | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | Community/Population Health | Process | AMA- PCPI | - | - | Population Health: Prevention | - | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 118 | Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | - | 0066 | 118 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy | Effective Clinical Care | Process | AMA- PCPI | AACF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 197 | Coronary Artery Disease (CAD): Lipid Control | - | 0074 | 197 | Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Correct measure description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result >=100 mg/dL and have a documented plan of care to achieve LDL-C <100mg/dL, including at a minimum the prescription of a statin | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 121 | Adult Kidney Disease: Laboratory Testing (Lipid Profile) | - | 1668 | 121 | Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period | Effective Clinical Care | Process | AMA- PCPI | - | - | Renal | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 122 | Adult Kidney Disease: Blood Pressure Management | - | - | 122 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) and proteinuria with a blood pressure < 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care | Effective Clinical Care | Outcome | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 123 | Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL | - | 1666 | 123 | Percentage of calendar months within a 12-month period during which a hemoglobin level is measured for patients aged 18 years and older with a diagnosis of advanced chronic kidney disease (CKD) (stage 4 or 5, not receiving Renal Replacement Therapy [RRT]) or End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also receiving erythropoiesis-stimulating agent (ESA) therapy have a hemoglobin level > 12.0 g/dL | Effective Clinical Care | Outcome | AMA- PCPI | - | - | Renal | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 173 | Preventive Care and Screening: Unhealthy Alcohol Use – Screening | - | - | 173 | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months | Community/Population Health | Process | AMA- PCPI | - | - | Behavioral Health | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | Q1 - Measure replaced by measure NQF #2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling. Measure 2152 endorsed via NQF Behavioral Health project in March 2014 Q2 – no changes |
| 176 | Rheumatoid Arthritis (RA): Tuberculosis Screening | - | - | 176 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD) | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | - | - | 177 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 178 | Rheumatoid Arthritis (RA): Functional Status Assessment | - | - | 178 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 179 | Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | - | - | 179 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 180 | Rheumatoid Arthritis (RA): Glucocorticoid Management | - | - | 180 | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 20 | Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician | - | 0270 | 020 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incision is required) | Patient Safety | Process | AMA- PCPI | - | - | Surgery | A -2016 | - | Full | Non-Endorsed/ Retired | - | - | - | - | - | The plan is to retire this measure Q2 - Measure retired |
| 21 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | - | 0268 | 021 | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis | Patient Safety | Process | AMA- PCPI | - | - | Surgery | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | - | - | Q1- Measure submitted and currently under review for maintenance of endorsement by NQFs Surgery Committee Q2 - NQF member and public comment period ongoing, ending on August 4th |
| 22 | Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) | - | 0271 | 022 | Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time | Patient Safety | Process | AMA- PCPI | - | - | Surgery | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | - | - | Q1 - Measure submitted and currently under review for maintenance of endorsement by NQFs Surgery Committee Q2 - NQF member and public comment period ongoing, ending on August 4th |
| 23 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | - | 0239 | 023 | Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Patient Safety | Process | AMA- PCPI | - | - | Safety | B - 2014 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 84 | Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment | - | 0395 | 084 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom quantitative hepatitis C virus (HCV) RNA testing was performed within 12 months prior to initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 85 | Hepatitis C: HCV Genotype Testing Prior to Treatment | - | 0396 | 085 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom hepatitis C virus (HCV) genotype testing was performed within 12 months prior to initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| 87 | Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment | - | 0398 | 087 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative hepatitis C virus (HCV) RNA testing was performed between 4-12 weeks after the initiation of antiviral treatment | Effective Clinical Care | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 183 | Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV) | - | 0399 | 183 | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A | Community/Population Health | Process | AMA- PCPI | - | - | Infectious disease | C - 2015 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 5 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 135v2 | 0081 | 005 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 198 | Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment | - | 0079 | 198 | Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior [any time in the past] LVEF assessment is documented within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 6 | Coronary Artery Disease (CAD): Antiplatelet Therapy | - | 0067 | 006 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 197 | Coronary Artery Disease (CAD): Lipid Control | - | 0074 | 197 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at a minimum the prescription of a statin | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 – no changes |
| 242 | Coronary Artery Disease (CAD): Symptom Management | - | - | 242 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with results of an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | ACCF | AHA | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 53 | Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting | - | 0047 | 053 | Percentage of patients aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q1 - NQF update submitted March 2014 Q2 - No changes |
| 64 | Asthma: Assessment of Asthma Control – Ambulatory Care Setting | - | 0001 | 064 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk) | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 231 | Asthma: Tobacco Use: Screening - Ambulatory Care Setting | - | - | 231 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma (or their primary caregiver) who were queried about tobacco use and exposure to second hand smoke within their home environment at least once during the one-year measurement period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 232 | Asthma: Tobacco Use: Intervention - Ambulatory Care Setting | - | - | 232 | Percentage of patients aged 5 through 64 years with a diagnosis of asthma who were identified as tobacco users (or their primary caregiver) who received tobacco cessation intervention at least once during the one-year measurement period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 51 | Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | - | 0091 | 051 | Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 52 | Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy | - | 0102 | 052 | Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 60% and have symptoms who were prescribed an inhaled bronchodilator | Effective Clinical Care | Process | AMA- PCPI | - | - | Pulmonary | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| 276 | Sleep Apnea: Assessment of Sleep Symptoms | - | - | 276 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 277 | Sleep Apnea: Severity Assessment at Initial Diagnosis | - | - | 277 | Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 278 | Sleep Apnea: Positive Airway Pressure Therapy Prescribed | - | - | 278 | Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 279 | Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | - | - | 279 | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 280 | Dementia: Staging of Dementia | - | - | 280 | Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 281 | Dementia: Cognitive Assessment | 149v2 | - | 281 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 282 | Dementia: Functional Status Assessment | - | - | 282 | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 283 | Dementia: Neuropsychiatric Symptom Assessment | - | - | 283 | Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 284 | Dementia: Management of Neuropsychiatric Symptoms | - | - | 284 | Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 285 | Dementia: Screening for Depressive Symptoms | - | - | 285 | Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 286 | Dementia: Counseling Regarding Safety Concerns | - | - | 286 | Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period | Patient Safety | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 287 | Dementia: Counseling Regarding Risks of Driving | - | - | 287 | Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 288 | Dementia: Caregiver Education and Support | - | - | 288 | Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period | Effective Clinical Care | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 133v2 | 0565 | 191 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery | Effective Clinical Care | Outcome | AMA- PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | Time-Limited Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 - Testing data submitted for consideration of full endorsement |
| 192 | Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 132v2 | 0564 | 192 | Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence | Patient Safety | Outcome | AMA- PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | Time-Limited Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 - Testing data submitted for consideration of full endorsement |
| 71 | Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer | - | 0387 | 071 | Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | NCCN | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 72 | Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients | - | 0385 | 072 | Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | NCCN | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 143 | Oncology: Medical and Radiation – Pain Intensity Quantified | 157v2 | 0384 | 143 | Percentage of patients, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA- PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 144 | Oncology: Medical and Radiation – Plan of Care for Pain | - | 0383 | 144 | Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA- PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 194 | Oncology: Cancer Stage Documented | - | 0386 | 194 | Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline American Joint Committee on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period | Effective Clinical Care | Process | AMA- PCPI | ASCO | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 359 | Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | - | - | 359 | Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 360 | Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | - | - | 360 | Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study | Patient Safety | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 361 | Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | - | - | 361 | Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements | Patient Safety | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 362 | Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes | - | - | 362 | Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 363 | Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive | - | - | 363 | Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed | Communication and Care Coordination | Structure | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 364 | Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | - | - | 364 | Percentage of final reports for CT imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (eg, follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors | Communication and Care Coordination | Process | AMA- PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 7 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 145v2 | 0070 | 007 | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or LVEF < 40% who were prescribed beta-blocker therapy | Effective Clinical Care | Process | AMA-PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 – no changes |
| 12 | Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation: | 143v2 | 0086 | 012 | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 18 | Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy | 167v2 | 0088 | 018 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months | Effective Clinical Care | Process | AMA-PCPI | - | - | Endocrine | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 19 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 142v2 | 0089 | 019 | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | - | - | Endocrine | A -2016 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 28 | Aspirin at Arrival for Acute Myocardial Infarction (AMI) | - | 0092 | 028 | Percentage of patients, regardless of age, with an emergency department discharge diagnosis of acute myocardial infarction (AMI) who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay | Effective Clinical Care | Process | AMA-PCPI | - | - | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| 31 | Stroke and Stroke Rehabilitation: Venous Thromboembolism (VTE) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage | - | 0240 | 031 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission | Effective Clinical Care | Process | AMA-PCPI | - | - | Neurology | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 32 | Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy | - | 0325 | 032 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an antithrombotic at discharge | Effective Clinical Care | Process | AMA-PCPI | - | - | Neurology | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 33 | Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at Discharge | - | 0241 | 033 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge | Effective Clinical Care | Process | AMA-PCPI | - | - | Neurology | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 35 | Stroke and Stroke Rehabilitation: Screening for Dysphagia | - | 0243 | 035 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care | Effective Clinical Care | Process | AMA-PCPI | - | - | Neurology | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 36 | Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered | - | 0244 | 036 | Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge | Effective Clinical Care | Process | AMA-PCPI | - | - | Neurology | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 45 | Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardiac Procedures) | - | 0637 | 045 | Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 48 hours of surgical end time | Patient Safety | Process | AMA-PCPI | - | - | Surgery | - | - | Full | Full Endorsement | - | - | - | - | - | Q1- Measure submitted and currently under review for maintenance of endorsement by NQFs Surgery Committee Q2 - NQF member and public comment period ongoing, ending on August 4th |
| 54 | Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain | - | 0090 | 054 | Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead electrocardiogram (ECG) performed | Effective Clinical Care | Process | AMA-PCPI | - | - | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q1 -Measure submitted for Phase 2 of the 2014 Cardiovascular Endorsement Maintenance project - Phase 2 start date yet to be determined by NQF Q2 – no changes |
| 55 | Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope | - | 0093 | 055 | Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead electrocardiogram (ECG) performed | Effective Clinical Care | Process | AMA-PCPI | - | - | Cardiovascular | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Planned Submission | - | - | - | - | - | The PCPI and the American College of Emergency Physicians elected not to submit the measure to NQF for maintenance of endorsement. PQRS data from 2011 suggested a relatively high rate of performance at 96.48% and we felt that the measure would fail to meet the performance gap sub-criterion within the “importance to measure and report” evaluation criterion. However, Syncope is a frequent complaint in the emergency department, accounting for one to three percent of all ED visits and hospital admissions in the US. An ECG remains a critical component of the initial evaluation of a patient presenting with syncope to determine the etiology and institute appropriate treatment strategies. We still collectively support the measure and have plans to maintain it as part of our emergency medicine measure set with no immediate plans for retirement. |
| 56 | Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Vital Signs | - | 0232 | 056 | Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with vital signs documented and reviewed | Effective Clinical Care | Process | AMA-PCPI | - | - | Pulmonary | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Planned Submission | - | - | - | - | - | Q2 – no changes |
| 59 | Emergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Empiric Antibiotic | - | 0096 | 059 | Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia (CAP) with an appropriate empiric antibiotic prescribed | Effective Clinical Care | Process | AMA-PCPI | - | - | Pulmonary | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| 67 | Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | - | 0377 | 067 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 68 | Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | - | 0378 | 068 | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 69 | Hematology: Multiple Myeloma: Treatment with Bisphosphonates | - | 0380 | 069 | Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 70 | Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | - | 0379 | 070 | Percentage of patients aged 18 years and older seen within a 12 month reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart | Effective Clinical Care | Process | AMA-PCPI | ASH | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 81 | Adult Kidney Disease: Hemodialysis Adequacy: Solute | - | 0323 | 081 | Percentage of calendar months within a 12-month period during which patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis three times a week for ≥ 90 days who have a spKt/V ≥ 1.2 | Communication and Care Coordination | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 82 | Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute | - | 0321 | 082 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving peritoneal dialysis who have a total Kt/V ≥ 1.7 per week measured once every 4 months | Communication and Care Coordination | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 83 | Hepatitis C: Confirmation of Hepatitis C Viremia | - | 0393 | 083 | Percentage of patients aged 18 years and older who are hepatitis C antibody positive seen for an initial evaluation for whom hepatitis C virus (HCV) RNA testing was ordered or previously performed | Effective Clinical Care | Process | AMA-PCPI | - | - | Infectious disease | C - 2015 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 91 | Acute Otitis Externa (AOE): Topical Therapy | - | 0653 | 091 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations | Effective Clinical Care | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | Time-Limited Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| 93 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use: | - | 0654 | 093 | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Communication and Care Coordination | Process | AMA-PCPI | - | - | HEENT | C - 2015 | - | Time-Limited Endorsement | Time-Limited Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| 99 | Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | - | 0391 | 099 | Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade | Effective Clinical Care | Process | AMA-PCPI | CAP | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 100 | Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | - | 0392 | 100 | Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade | Effective Clinical Care | Process | AMA-PCPI | CAP | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 129v3 | 0389 | 102 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer | Efficiency and Cost Reduction | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q2 | TBD by NQF | - | Q2 - NQF update submitted June 2014 |
| 104 | Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients | - | 0390 | 104 | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist) | Effective Clinical Care | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 106 | Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity | - | 0103 | 106 | Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | AMA-PCPI | - | - | Behavioral Health | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | Q2 – no changes |
| 107 | Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 161v2 | 0104 | 107 | Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified | Effective Clinical Care | Process | AMA-PCPI | - | - | Behavioral Health | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q1 - Endorsement renewed in 2/14 Q2 – no changes |
| 109 | Osteoarthritis (OA): Function and Pain Assessment | - | 0050 | 109 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | - | - | Musculoskeletal | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | The American Academy of Orthopedic Surgeons intends to potentially submit this measure for endorsement. The measure lost endorsement because of time and resource constraints that precluded submission of measure for maintenance of endorsement. We continue to support this measure and may plan to resubmit at the next available opportunity. Q2 – no changes |
| 137 | Melanoma: Continuity of Care – Recall System | - | 0650 | 137 | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment | Effective Clinical Care | Structure | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 138 | Melanoma: Coordination of Care | - | 0561 | 138 | Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis | Communication and Care Coordination | Process | AMA-PCPI | - | - | Cancer | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | Q2 – no changes |
| 142 | Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications | - | 0051 | 142 | Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with an assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications | Effective Clinical Care | Process | AMA-PCPI | - | - | Musculoskeletal | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | Q1 -The American Academy of Orthopedic Surgeons intends to potentially submit this measure for endorsement. The measure lost endorsement because of time and resource constraints that precluded submission of measure for maintenance of endorsement. Q2 – no changes |
| 145 | Radiology: Exposure Time Reported for Procedures Using Fluoroscopy | - | 0510 | 145 | Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time | Patient Safety | Process | AMA-PCPI | - | - | Safety | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | - | - | Measure submitted and currently under review for maintenance of endorsement by NQFs Patient Safety Committee |
| 146 | Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening | - | 0508 | 146 | Percentage of final reports for screening mammograms that are classified as “probably benign” | Efficiency and Cost Reduction | Process | AMA-PCPI | - | - | Efficiency | A -2016 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | - | - | 147 | Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed | Communication and Care Coordination | Structure | AMA-PCPI | - | - | - | - | - | Non-Endorsed/Lost Endorsement | Non-Endorsed/ Lost Endorsement | - | - | - | - | - | Q2 – no changes |
| 156 | Oncology: Radiation Dose Limits to Normal Tissues | - | 0382 | 156 | Percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer receiving 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues | Patient Safety | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 185 | Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | - | 0659 | 185 | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy | Communication and Care Coordination | Process | AMA-PCPI | - | - | GI/GU | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Received full endorsement 12/13 Q2 – no changes |
| 195 | Radiology: Stenosis Measurement in Carotid Imaging Reports | - | 0507 | 195 | Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement | Effective Clinical Care | Process | AMA-PCPI | - | - | Neurology | C - 2015 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 224 | Melanoma: Overutilization of Imaging Studies in Melanoma | - | 0562 | 224 | Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered | Efficiency and Cost Reduction | Process | AMA-PCPI | - | - | Cancer | B - 2014 | - | Full | Full Endorsement | - | - | Q4 | TBD by NQF | - | Q2 – no changes |
| 225 | Radiology: Reminder System for Mammograms | - | 0509 | 225 | Percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram | Communication and Care Coordination | Structure | AMA-PCPI | - | - | Efficiency | A -2016 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 245 | Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure | - | - | 245 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique | Effective Clinical Care | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 246 | Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse Measure) | - | - | 246 | Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings | Effective Clinical Care | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 247 | Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence | - | - | 247 | Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 248 | Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence | - | - | 248 | Percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12-month reporting period | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 320 | Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients: | - | 0658 | 320 | Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Communication and Care Coordination | Process | AMA-PCPI | - | - | GI/GU | C - 2015 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Received full endorsement 12/13 |
| 325 | Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | - | - | 325 | Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | - | 1525 | 326 | Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism | Patient Safety | Process | AMA-PCPI | ACCF | AHA | Cardiovascular | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Measure submitted for Phase 2 of the 2014 Cardiovascular Endorsement Maintenance project - Phase 2 start date yet to be determined by NQF |
| 328 | Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/Dl | - | 1667 | 328 | Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL | Effective Clinical Care | Outcome | AMA-PCPI | - | - | Renal | B - 2014 | - | Full | Full Endorsement | - | - | Q3 | TBD by NQF | - | Q2 – no changes |
| 329 | Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | - | - | 329 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 330 | Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | - | - | 330 | Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use) | - | - | 331 | Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 7 days of diagnosis or within 10 days after onset of symptoms | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis | - | - | 332 | Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, without clavulante, as a first line antibiotic at the time of diagnosis | Effective Clinical Care | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 333 | Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse) | - | - | 333 | Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis | Efficiency and Cost Reduction | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 334 | Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | - | - | 334 | Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis | Effective Clinical Care | Efficiency | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 335 | Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks | - | - | 335 | Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication | Patient Safety | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 336 | Maternity Care: Post-Partum Follow-Up and Care Coordination | - | - | 336 | Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning | Communication and Care Coordination | Process | AMA-PCPI | - | - | - | - | - | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | - | TBD by NQF | - | Q2 – no changes |
| 382 | Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 177v2 | 1365 | 382 | Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk | Patient Safety | Process | AMA-PCPI | - | - | Behavioral Health | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | TBD by NQF | - | Q2 – no changes |
| - | AMPA | ||||||||||||||||||||
| 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | - | 0417 | 126 | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months | Effective Clinical Care | Process | APMA | - | - | Endocrine | - | Full | Non-Endorsed/Planned Submission | Non-Endorsed/ Submitted Pending Review | - | - | - | Was resubmitted for full review 6/6/14 | This measure was reviewed in the Endocrine review in March 2014. There were issues identified by the committee. The measure was withdrawn for reivew by measure developer and will be revised and resubmitted for June 2014 review. | Changes were made based on committee review and resubmitted for full review on 6/6/14 |
| 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | - | 0416 | 127 | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing | Effective Clinical Care | Process | APMA | - | - | Endocrine | - | Full | Non-Endorsed/Planned Submission | Non-Endorsed/ Submitted Pending Review | - | - | - | Was resubmitted for full review 6/6/14 | This measure was reviewed in the Endocrine review in March 2014. There were issues identified by the committee. The measure was withdrawn for reivew by measure developer and will be revised and resubmitted for June 2014 review. | Changes were made based on committee review and resubmitted for full review on 6/6/14 |
| - | AQC | ||||||||||||||||||||
| 261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | - | - | 261 | Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness | Communication and Care Coordination | Process | AQC | - | - | - | - | Not endorsed - not pursing endorsement | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | - | - |
| - | ASA | ||||||||||||||||||||
| 30 | Perioperative Care: Timing of Prophylactic Antibiotic—Administering Physician | - | 0269 | 030 | Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures with the indications for prophylactic parenteral antibiotics for whom administration of a prophylactic parenteral antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) | Patient Safety | Process | AMA-PCPI | NCQA | - | Surgery | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | - | - | Q1 - Measure submitted and currently under review for maintenance of endorsement by NQFs Surgery Committee; Q2: Under review by NQFs Surgery Committee |
| 76 | Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol | - | 0464 | 076 | Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed | Patient Safety | Process | AMA-PCPI | - | - | Safety | B - 2014 | - | Full | Full Endorsement | - | - | TBD by NQF | - | - | Q1 - Measure submitted and currently under review for maintenance of endorsement by NQFs Patient Safety Committee Q2 - Under review by NQFs Patient Safety Committee |
| 193 | Perioperative Temperature Management | - | 0454 | 193 | Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time | Patient Safety | Process | AMA-PCPI | - | - | Surgery | A -2016 | - | Full | Full Endorsement | - | - | TBD by NQF | - | - | Q1 - Measure submitted and currently under review for maintenance of endorsement by NQFs Surgery Committee Q2 - Under review by NQF Surgery Committee |
| - | ASBS | ||||||||||||||||||||
| 262 | Image Confirmation of Successful Excision of Image–Localized Breast Lesion | - | - | 262 | Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy. | Patient Safety | Process | ASBS | - | - | N/A | - | non-endorsed | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | N/A | Measure will be reviewed and any necessary updates will be made by 8/1/2014 | Q1-N/A Q2-N/A |
| 263 | Preoperative Diagnosis of Breast Cancer | - | - | 263 | The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method | Effective Clinical Care | Process | ASBS | - | - | N/A | - | non-endorsed | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | N/A | Measure will be reviewed and any necessary updates will be made by 8/1/2014 | Q1-N/A Q2-N/A |
| 264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer | - | - | 264 | The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure | Effective Clinical Care | Process | ASBS | - | - | N/A | - | non-endorsed | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | N/A | Measure will be reviewed and any necessary updates will be made by 8/1/2014 | Q1-N/A Q2-N/A |
| - | ACG | ||||||||||||||||||||
| 343 | Screening Colonoscopy Adenoma Detection Rate Measure | - | - | 343 | The percentage of patients age 50 years or older with at least one adenoma or other colorectal cancer precursor or colorectal cancer detected during screening colonoscopy | Effective Clinical Care | Outcome | ASGE | ACG | AGA | Gastroenterology or another appropriate project | - | N/A | Non-Endorsed/Planned Submission | - | - | - | Q2 | Year or exact date TBD | Q3-submitting to NQF measure inventory pipeline | Q2-awaiting determination by NQF when measure can be scheduled for review |
| - | CAP | ||||||||||||||||||||
| 249 | Barretts Esophagus | - | - | 249 | Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia | Effective Clinical Care | Structure | CAP | - | - | Cancer | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD | - | Q4 Annual update submitted December 2013 |
| 250 | Radical Prostatectomy Pathology Reporting | - | - | 250 | Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status | Effective Clinical Care | Structure | CAP | - | - | Cancer | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD | - | Q4 Annual update submitted December 2013 |
| 251 | Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | - | - | 251 | This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer | Effective Clinical Care | Structure | CAP | - | - | Cancer | C - 2015 | - | Full | Full Endorsement | - | - | Q4 | TBD | - | Q4 Annual update submitted December 2013 |
| - | FOTO | ||||||||||||||||||||
| 217 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments | - | 0422 | 217 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the knee in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Process | F0T0 | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| 218 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments | - | 0423 | 218 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the hip in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| 219 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments | - | 0424 | 219 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lower leg, foot or ankle in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| 220 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments | - | 0425 | 220 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lumbar spine in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| 221 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments | - | 0426 | 221 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the shoulder in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| 222 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments | - | 0427 | 222 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the elbow, wrist or hand in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| 223 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments | - | 0428 | 223 | Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the neck, cranium, mandible, thoracic spine, ribs, or other general orthopedic impairment in which the change in their Risk-Adjusted Functional Status is measured | Communication and Care Coordination | Outcome | FOTO | - | - | Person and Family Centered Care-Phase 2 | - | Full | Full | Full Endorsement | - | - | - | September, 2014 | Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO was informed our measures were assigned to the “Musculoskeletal review committee which convenes this year projected to be in Q4." Recontact with NQF in October 2013 to determine review session and deadline date and we were informed that our seven measures are assigned to the second phase of the “Person and Family Centered Care” project and that we should move forward with completing the maintenance forms for these measures for submission deadline of September 12, 2014. We are currently preparing our update information for submission to NQF by this deadline. | Qtr 1 2014: N/A Qtr 2 2014: On target to submit our Endorsement Maintenance Documents to NQF by the submission deadline date of September 12, 2014. |
| - | HRS | ||||||||||||||||||||
| 348 | HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | - | - | 348 | Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD | Effective Clinical Care | Outcome | HRS | - | - | see column V | - | non-endorsed: Withdrew the measure at NQF’s suggestion from the current cardiac project because both NQF and we felt it was better considered in concert with the hospital-level analysis corollary when that comes up for endorsement maintenance. | Non-Endorsed | Non-Endorsed | - | - | - | - | - | Withdrew the measure at NQF’s suggestion from the current cardiac project because both NQF and we felt it was better considered in concert with the hospital-level analysis corollary when that comes up for endorsement maintenance. |
| - | HRSA | ||||||||||||||||||||
| 338 | HIV Viral Load Suppression | - | 2082 | 338 | The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year | Effective Clinical Care | Outcome | - | - | - | Infectious Disease | C - 2015 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | - | eMeasure in progress | Q1 -annual update submitted 4/21/2014 Q2 - no changes |
| 339 | Prescription of HIV Antiretroviral Therapy | - | 2083 | 339 | Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year | Effective Clinical Care | Process | - | - | - | Infectious Disease | C - 2015 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | - | eMeasure in progress | Q1 -annual update submitted 4/21/2014 Q2 - no changes |
| 340 | HIV Medical Visit Frequency | - | 2079 | 340 | Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits | Efficiency and Cost Reduction | Process | - | - | - | Infectious Disease | C - 2015 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | - | eMeasure in progress | Q1 -annual update submitted 4/21/2014 Q2 - no changes |
| 341 | Gap in HIV Medical Visits | - | 2080 | 341 | Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months | Efficiency and Cost Reduction | Process | - | - | - | Infectious Disease | C - 2015 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | - | eMeasure in progress | Q1 -annual update submitted 4/21/2014 Q2 - no changes |
| - | MNCM | ||||||||||||||||||||
| 319 | Diabetes Composite: Optimal Diabetes Care | - | 0729 | 319 | Patients ages 18 through 75 with a diagnosis of diabetes, who meet all the numerator targets of this composite measure: • A1c < 8.0% • LDL < 100 mg/dL • blood pressure < 140/90 mmHg • tobacco non-user and (for patients with a diagnosis of ischemic vascular disease) daily aspirin use unless contraindicated | Effective Clinical Care | Outcome | MNCM | - | - | Endocrine | B - 2014 | Full | Full | Full Endorsement | - | - | - | 12/1/14 | Cholesterol component changes necessary based on Nov 2013 ACC/AHA new guidelines. | Q1- Annual update submitted 9/11/2012 Q2- Annual update submitted 9/11/2012 |
| 349 | Optimal Vascular Composite | - | 0076 | 349 | Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who have optimally managed modifiable risk factors demonstrated by meeting all of the numerator targets of this patient level all-or-none composite measure: LDL less than 100, blood pressure less than 140/90, tobacco-free status, and daily aspirin use | Effective Clinical Care | Outcome | MNCM | - | - | Cardiovascular | A -2016 | Full | Full | Full Endorsement | - | - | - | - | Cholesterol component changes necessary based on Nov 2013 ACC/AHA new guidelines. | Q1- Annual update submitted 4/3/2013 Q2- Annual update submitted 4/3/2013 |
| 370 | Depression Remission at Twelve Months | 159v2 | 0710 | 370 | Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment | Effective Clinical Care | Outcome | MNCM | - | - | Behavioral | B - 2014 | Full | Full | Full Endorsement | - | - | - | 7/25/14 | - | Q1- Annual update submitted 4/24/2013 Q2- Annual update submitted 4/24/2013 |
| 371 | Depression Utilization of the PHQ-9 Tool | 160v2 | 0712 | 371 | Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4 month period in which there was a qualifying visit. | Effective Clinical Care | Process | MNCM | - | - | Behavioral | B - 2014 | Full | Full | Full Endorsement | - | - | - | 7/25/14 | - | Q1- Annual update submitted 4/24/2013 Q2- Annual update submitted 4/24/2013 |
| - | NCQA | ||||||||||||||||||||
| 66 | Appropriate Testing for Children with Pharyngitis | 146v2 | 0002 | 066 | Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode | Efficiency and Cost Reduction | Process | NCQA | - | - | HEENT | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No Changes |
| 236 | Controlling High Blood Pressure | 165v2 | 0018 | 236 | Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period. | Effective Clinical Care | Outcome | NCQA | - | - | Cardiovascular | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1- Q1 2013 - Annual update submitted 03/2013 Q2 - No Changes |
| 238 | Use of High-Risk Medications in the Elderly | 156v2 | 0022 | 238 | Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications. | Patient Safety | Process | NCQA | - | - | Patient Safety | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No changes |
| 239 | Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 155v2 | 0024 | 239 | Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity | Community/Population Health | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No changes |
| 310 | Chlamydia Screening for Women | 153v2 | 0033 | 310 | Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period | Community/Population Health | Process | NCQA | - | - | Perinatal & Reproductive Health | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No Changes |
| 311 | Use of Appropriate Medications for Asthma | 126v2 | 0036 | 311 | Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Pulmonary/Critical Care | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No Changes |
| 240 | Childhood Immunization Status | 117v2 | 0038 | 240 | Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday | Community/Population Health | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No Changes |
| 312 | Use of Imaging Studies for Low Back Pain | 166v3 | 0052 | 312 | Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. | Efficiency and Cost Reduction | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1- Under maintenance review under the Musculoskeletal project. Currently in Public and Member comment phase. Q2 - Under maintenance review under the Musculoskeletal project. Currently in Public and Member comment phase. | Q1- No changes Q2- No changes |
| 65 | Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 154v2 | 0069 | 065 | Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode | Efficiency and Cost Reduction | Process | NCQA | - | - | Infectious Diseases | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1- No changes Q2- No changes |
| 366 | ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication | 136v3 | 0108 | 366 | ercentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health Phase III | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Will go through maintenance review under the Behavioral Health Phase III project beginning in Q3 2014. Initial submission deadline is 7/25/14. Q2 - Will go through maintenance review under the Behavioral Health Phase III project beginning in Q3 2014. Initial submission deadline is 7/25/14. | Q1- No changes Q2- No changes |
| 1 | Diabetes: Hemoglobin A1c Poor Control | 122v2 | 0059 | 001 | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period | Effective Clinical Care | Outcome | NCQA | - | - | Endocrine Phase I | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Went through public and member comment phase for Endocrine Phase 1 project. Q2 - Under maintenance review under the Endocrine Phase I project. Currently in the Member Voting phase. | Q1- No changes Q2- No changes |
| 111 | Pneumonia Vaccination Status for Older Adults | 127v2 | 0043 | 111 | Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 -Q4 2013 - Annual update submitted 12/2013 Q2 - No changes |
| 112 | Breast Cancer Screening | 125v2 | (2372 - New NQF #) | 112 | Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | B - 2014 | Non-Endorsed/Has been submitted for current 2014 project. | Non-Endorsed/ Submitted Pending Review | Non-Endorsed/ Submitted Pending Review | - | - | - | 2014 | Q1 - Under maintenance review under the Health & Well-Being project. Currently in Public and Member comment phase. Q2 - Under maintenance review under the Health & Well-Being project. Currently in Public and Member comment phase. | Q1- No changes Q2- No changes |
| 113 | Colorectal Cancer Screening | 130v2 | 0034 | 113 | Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 -Q4 2013 - Annual update submitted 12/2013 Q2 - No changes |
| 318 | Falls: Screening for Fall Risk | 139v2 | 0101 | 318 | Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period | Patient Safety | Process | NCQA | - | - | Patient Safety | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 2 | Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL) | 163v2 | 0064 | 002 | Percentage of patients 18–75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dL) during the measurement period | Effective Clinical Care | Outcome | NCQA | - | - | Endocrine Phase III | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Will go through maintenance review under the Endocrine Phase III project beginning in Q4 2014. Initial submission deadline is 12/5/14. Q2 - Will go through maintenance review under the Endocrine Phase III project beginning in Q4 2014. Initial submission deadline is 12/5/14. | Q1- No changes Q2- No changes |
| 117 | Diabetes: Eye Exam | 131v2 | 0055 | 117 | Percentage of patients 18 through 75 years of age with a diagnosis of diabetes (type 1 and type 2) who had a retinal or dilated eye exam in the measurement period or a negative retinal or dilated eye exam (negative for retinopathy) in the year prior to the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Went through public and member comment phase for Endocrine Phase 1 project. Q2 - Under maintenance review under the Endocrine Phase I project. Currently in the Member Voting phase. | Q1- No changes Q2- No changes |
| 119 | Diabetes: Medical Attention for Neuropathy | 134v2 | 0062 | 119 | The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Went through public and member comment phase for Endocrine Phase 1 project. Q2 - Under maintenance review under the Endocrine Phase I project. Currently in the Member Voting phase. | Q1- No changes Q2- No changes |
| 163 | Diabetes: Foot Exam | 123v2 | 0056 | 163 | Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Went through public and member comment phase for Endocrine Phase 1 project. Q2 - Under maintenance review under the Endocrine Phase I project. Currently in the Member Voting phase. | Q1- No changes Q2- No changes |
| 108 | Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy | - | 0054 | 108 | Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Under maintenance review under the Musculoskeletal project. Currently in Public and Member comment phase. Q2 - Under maintenance review under the Musculoskeletal project. Currently in Public and Member comment phase. | Q1- No changes Q2- No changes |
| 148 | Back Pain: Initial Visit | - | 0322 | 148 | The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who had back pain and function assessed during the initial visit to the clinician for the episode of back pain | Efficiency and Cost Reduction | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full | Full | Non-Endorsed/ Retired | - | - | - | - | Q1 - Went through maintenance review under the Musculoskeletal project in Q1 of 2014. However, NCQA did not seek NQF re-endorsement for this measure. Endorsement removed 4/3/14. Q2 - No changes | Q1- No changes Q2- No changes |
| 149 | Back Pain: Physical Exam | - | 0319 | 149 | Percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received a physical examination at the initial visit to the clinician for the episode of back pain | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full | Full | Non-Endorsed/ Retired | - | - | - | - | Q1 - Went through maintenance review under the Musculoskeletal project in Q1 of 2014. However, NCQA did not seek NQF re-endorsement for this measure. Endorsement removed 4/3/14. Q2 - No changes | Q1- No changes Q2- No changes |
| 150 | Back Pain: Advice for Normal Activities | - | 0314 | 150 | The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice for normal activities at the initial visit to the clinician for the episode of back pain | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full | Full | Non-Endorsed/ Retired | - | - | - | - | Q1 - Went through maintenance review under the Musculoskeletal project in Q1 of 2014. However, NCQA did not seek NQF re-endorsement for this measure. Endorsement removed 4/3/14. Q2 - No changes | Q1- No changes Q2- No changes |
| 151 | Back Pain: Advice Against Bed Rest | - | 0313 | 151 | The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice against bed rest lasting four days or longer at the initial visit to the clinician for the episode of back pain | Effective Clinical Care | Process | NCQA | - | - | Musculoskeletal | B - 2014 | Full | Full | Non-Endorsed/ Retired | - | - | - | - | Q1 - Went through maintenance review under the Musculoskeletal project in Q1 of 2014. However, NCQA did not seek NQF re-endorsement for this measure. Endorsement removed 4/3/14. Q2 - No changes | Q1- No changes Q2- No changes |
| 204 | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | 164v2 | 0068 | 204 | Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Cardiovascular | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 236 | Controlling High Blood Pressure | 165v2 | 0018 | 236 | Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period. | Effective Clinical Care | Outcome | NCQA | - | - | Cardiovascular | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2013 - Annual update submitted 03/2013 Q2 - No changes |
| 241 | Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dL) | 182v3 | 0075 | 241 | Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dL) | Effective Clinical Care | Outcome | NCQA | - | - | Cardiovascular | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 160 | HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | 52v2 | 0405 | 160 | Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis | Effective Clinical Care | Process | NCQA | - | - | Infectious Diseases | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 9 | Anti-Depressant Medication Management | 128v2 | 0105 | 009 | Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months). | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health Phase II | C - 2015 | Full | Full | Full Endorsement | - | - | - | 2015 | Q1- No changes Q2- No changes | Q1 - Endorsement maintenance was completed on 2/28/14 and endorsement was renewed. Q2 - no changes |
| 116 | Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use | - | 0058 | 116 | Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode | Efficiency and Cost Reduction | Process | NCQA | - | - | Infectious Diseases | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1- No changes Q2- No changes |
| 305 | Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 137v2 | 0004 | 305 | Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit. | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No Changes |
| 309 | Cervical Cancer Screening | 124v2 | 0032 | 309 | Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer | Effective Clinical Care | Process | NCQA | - | - | Health & Well-Being | C - 2015 | Full | Full | Full Endorsement | - | - | Q4 | 2015 | Q1- No changes Q2- No changes | Q1 - Q4 2013 - Annual update submitted 12/2013 Q2 - No changes |
| 365 | Hemoglobin A1c Test for Pediatric Patients | 148v2 | 0060 | 365 | Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period | Effective Clinical Care | Process | NCQA | - | - | Endocrine Phase I | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Went through public and member comment phase for Endocrine Phase 1 project. Q2 - Under maintenance review under the Endocrine Phase I project. Currently in the Member Voting phase. | Q1- No changes Q2- No changes |
| 368 | HIV/AIDS: Medical Visit | 62v2 | 0403 | 368 | Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit | Effective Clinical Care | Process | NCQA | - | - | N/A | - | Non-endorsed | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | Q1- No changes Q2- No changes | Q1 - This measure went through maintenance review under the Infectious Diseases project back in 2012. The measure was not recommended for re-endorsement. Q2 - No changes |
| 372 | Maternal Depression Screening | 82v1 | 1401 | 372 | The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child’s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life. | Effective Clinical Care | Process | NCQA | - | - | Behavioral Health Phase III | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Will go through maintenance review under the Behavioral Health Phase III project beginning in Q3 2014. Initial submission deadline is 7/25/14. Q2 - Will go through maintenance review under the Behavioral Health Phase III project beginning in Q3 2014. Initial submission deadline is 7/25/14. | Q1 - Q1 2013 - Annual update submitted 03/2013 Q2 - No changes |
| 46 | Medication Reconciliation | - | 0097 | 046 | Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented | Patient Safety | Process | AMA- PCPI | NCQA | - | Patient Safety | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 39 | Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older | - | 0046 | 039 | Percentage of female patients aged 65 years and older who have a central dual-energy X- ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. Q2 - Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | Q1- No changes Q2- No changes |
| 48 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | - | 0098 | 048 | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | N/A | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | Q1- No changes Q2- No changes | Q1- No changes Q2- No changes |
| 159 | HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed | - | 0404 | 159 | Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | - | 0409 | 205 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection | Effective Clinical Care | Process | AMA- PCPI | NCQA | - | Infectious disease | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 24 | Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0045 | 024 | Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. Q2 - Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | Q1- No changes Q2- No changes |
| 40 | Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older | - | 0048 | 040 | Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full | Full | Full Endorsement | - | - | - | 2014 | Q1 - Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. Q2 - Will go through maintenance review under the Endocrine Phase II project beginning in Q3 2014. Initial submission deadline is 6/6/14. | Q1- No changes Q2- No changes |
| 41 | Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older | - | 0049 | 041 | Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | Endocrine Phase II | B - 2014 | Full | Full | Non-Endorsed/ No Plan to Submit | - | - | - | - | Q1- No changes Q2- No changes | Q1 - No changes Q2 - NCQA did not seek re-endorsement of this measure during the Endocrine Phase II project. After review by our expert workgroup, we have concluded this measure does not address a significant quality gap and should be retired from the PQRS program. Notification of this was sent to PQMM on 5/20/14. |
| 47 | Advance Care Plan | - | 0326 | 047 | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Care Coordination | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 49 | Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older | - | 0099 | 049 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months | Effective Clinical Care | Process | AMA-PCPI | NCQA | - | N/A | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | Q1- No changes Q2- No changes | Q1- No changes Q2- No changes |
| 50 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | - | 0100 | 050 | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Patient and Caregiver-Centered Experience and Outcomes | Process | AMA-PCPI | NCQA | - | N/A | - | - | Non-Endorsed/ No Plan to Submit | Non-Endorsed/ No Plan to Submit | - | - | - | - | Q1- No changes Q2- No changes | Q1- No changes Q2- No changes |
| 154 | Falls: Risk Assessment | - | 0101 | 154 | Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months | Patient Safety | Process | AMA-PCPI | NCQA | - | Patient Safety | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| 155 | Falls: Plan of Care | - | 0101 | 155 | Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months | Communication and Care Coordination | Process | AMA-PCPI | NCQA | - | Patient Safety | C - 2015 | Full | Full | Full Endorsement | - | - | Q1 | 2015 | Q1- No changes Q2- No changes | Q1 - Q1 2014 - Annual update submitted 03/2014 Q2 - No changes |
| - | ONC_HITECH (Booz Allen) | ||||||||||||||||||||
| 373 | Hypertension: Improvement in Blood Pressure | 65v3 | - | 373 | Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period. | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted clinical and technicaL feasibility and parallel forms reliability testing at two sites in late 2012 and early 2013 | Q1 - Annual update submitted. ONC HITECH team plans to have completed NQF documentation and submission by 09/29/2014 (if theres a formal call) or to have NQF submission documentation submitted to ONC by 09/29/2014 (if there is a not a formal call) Q2 - No changes |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | 50v2 | N/A | 374 | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted clinical and technical feasibility at three sites in late 2012 and parallel forms reliability testing at two sites in early 2013 | Q1 - Annual update submitted. ONC HITECH team is working on an expanded form of this MU2 measure to capture the critical information communicated with the referral to the specialist and the specialist sending report to the referring physician Q2 - No changes |
| 375 | Functional Status Assessment for Knee Replacement | 66v2 | - | 375 | Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments. | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted clinical and technical feasibility and parallel forms reliability testing at one site in early 2013 | Q1 - Annual update submitted. ONC HITECH team created the MU2 process measure as a building block measure and is working on an expanded outcome measure proposed for MU3. Since the MU-3 measure will ultimately replace the MU-2 measure, we would defer to ONC and CMS on plans for the current MU-2 measure. Q2- No changes |
| 376 | Functional Status Assessment for Hip Replacement | 56v2 | - | 376 | Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted clinical and technical feasibility and parallel forms reliability testing at one site in early 2013 | Q1 - Annual update submitted. ONC HITECH team created the MU2 process measure as a building block measure and is working on an expanded outcome measure proposed for MU3. Since the MU-3 measure will ultimately replace the MU-2 measure, we would defer to ONC and CMS on plans for the current MU-2 measure. Q2 - No changes |
| 377 | Functional Status Assessment for Complex Chronic Conditions | 90v3 | N/A | 377 | Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted initial feasibilty testing at three sites in early 2012. | Q1 - Annual update submitted. ONC HITECH team created the MU2 process measure as a building block measure and is working on an expanded outcome measure proposed for MU3 (Functional Status Assessment and Goal Achievement for Patients with Congestive Heart Failure). Since the MU-3 measure will ultimately replace the MU-2 measure, we would defer to ONC and CMS on plans for the current MU-2 measure Q2 - No changes |
| 378 | Children Who Have Dental Decay or Cavities | 75v2 | N/A | 378 | Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team completed reliability and validity testing at a three urban and rural locations in early 2013 and shared/presented the testing outcomes with the ADA | Q1 - Annual update submitted. ONC HITECH team understanding is the ADA is working on an updated and/or replacement measure for Stage 3. We would need to defer to ADA, CMS and ONC on the decision to pursue NQF endorsement for the MU-2 measure. Q2 - No changes |
| 379 | Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 74v3 | - | 379 | Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period. | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team completed reliability and validity testing at a three urban and rural locations in early 2013 and shared/presented the testing outcomes with the ADA | Q1 - Annual update submitted. ONC HITECH team understanding is the ADA is working on an updated and/or replacement measure for Stage 3. We would need to defer to ADA, CMS and ONC on the decision to pursue NQF endorsement for the MU-2 measure. Q2 - No changes |
| 380 | ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range | 179v2 | - | 380 | Average percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR) during the measurement period | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted clinical and technical feasibility testing at two sites in late 2012 and early 2013. Due to the complexity of the TTR calculations involved we did not perform parallel forms reliability with our test sites and instead worked with VA SMEs to leverage and evaluate the supplemental SQL logic we included in the MU2 measure | Q1 - Annual update submitted. The ONC HITECH team is working on a revised ADE TTR outcome measure for MU3, based on updated CHEST 2012 guidelines and a paired INR process measure proposed for MU3. Since the proposed MU3 process and outcome measures will be based on current guidelines, we defer to CMS and ONC on the decision to pursue NQF endorsement for the MU-2 measure. Q2 - No changes |
| 381 | HIV/AIDS: RNA Control for Patients with HIV | 77v2 | - | 381 | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/mL. | Non-Endorsed/No Plan to Submit | Non-Endorsed/No Plan to Submit | - | - | - | - | - | - | - | - | - | - | - | - | ONC HITECH team conducted clinical and technical feasibility testing at two sites in late 2012 and early 2013. | Q1 - No changes/issues for annual update. ONC HITECH: This measure was originally a respecification of an NQF-endorsed measure. Our understanding is NQF dropped endorsement for the parent measure because HRSA had a similar measure they preferred over this measure. However, CMS and ONC decided to keep the measure for MU2 with the thought it be replaced by the e-spec of the HRSA measure in Stage 3. While the ONC HITECH team does not recommend pursuing NQF endorsement for the MU2 measure, we defer to CMS, HRSA and ONC for a formal decision. Q2 - No changes |
| - | Quality Insights of Pennsylvania | ||||||||||||||||||||
| 134 | Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 2v3 | 0418 | 134 | Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. | Community/Population Health | Process | CMS | - | - | Behavioral Health | A -2016 | Full | Full | Full Endorsement | - | - | Q1 | 2016 | N/A | Q1- Re-Endorsed 2/28/14 Q2 - No updates |
| 130 | Documentation of Current Medications in the Medical Record | 68v3 | 0419 | 130 | Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. | Patient Safety | Process | CMS | - | - | Patient Safety | B - 2014 | Full | Full | Full Endorsement | - | - | Q2 | 2017 | N/A | Q1- No activity Q2- Annual Review submitted |
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up | 69v2 | 0421 | 128 | Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥ 18.5 and < 25 | Community/Population Health | Process | CMS | - | - | Health and Well Being | A -2016 | Full | Full | Full Endorsement | - | - | Q1 | 2016 | N/A | Q1 - Annual Update submitted March 2014. CMS is considering changing Comprehensive Review Due Date based on release of new guidelines Q2 - No updates |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 22v2 | - | 317 | Percentage of patients aged 18 years and older seen during the measurement period who were screened for high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated | Community/Population Health | Process | CMS | - | - | Cardiovascular | A -2016 | Non-Endorsed | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | Q1 | ? | Q1-Measure is being re-tooled by Interagency Workgroup Q2- this measure has been placed on HOLD by CMS | Q1 - N/A Q2 - N/A |
| 44 | Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | - | 0236 | 044 | Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision | Effective Clinical Care | Process | CMS | - | - | Surgery | A -2016 | Full | Full | Full Endorsement | - | - | Q1 | 2016 | - | Q1 - N/A Q2 - N/A |
| 131 | Pain Assessment and Follow-Up | - | 0420 | 131 | Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present | Communication and Care Coordination | Process | CMS | - | - | Health and Well Being | A -2016 | Full | Full | Full Endorsement | - | - | Q1 | 11/7/14 | - | Q1 - measure has been submitted for comprehensive review Q2 - no updates |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | - | - | 181 | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen | Patient Safety | Process | CMS | - | - | Safety | B - 2014 | Not endorsed | Non-Endorsed/Submitted Pending Review | Non-Endorsed/ No Plan to Submit | - | - | - | 2014 | - | Q1 - measure has been submitted for initial comprehensive reivew. In person meeting April 18th or 19th Q2 - Failed NQF endorsment |
| 182 | Functional Outcome Assessment | - | - | 182 | Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies | Communication and Care Coordination | Process | CMS | - | - | Person and Family Centered Care | C - 2015 | Not endorsed | Non-Endorsed/ Planned Submission | Non-Endorsed/ Planned Submission | - | - | Q3 | 11/7/14 | - | Q1 - N/A Q2 - No updates |
| 228 | Heart Failure (HF): Left Ventricular Function (LVF) Testing | - | - | 228 | Percentage of patients 18 years and older with Left Ventricular Function (LVF) testing documented as being performed within the previous 12 months or LVF testing performed prior to discharge for patients who are hospitalized with a principal diagnosis of Heart Failure (HF) during the reporting period | Effective Clinical Care | Process | CMS | - | - | Cardiovascular | A -2016 | Not endorsed | Non-Endorsed/Sybmitted Pending Review | Non-Endorsed/ No Plan to Submit | - | - | - | 2014 | This measure will be retired for 2015 | Q1 - measure has been submitted for comprehensive review Q2 - submission was withdrawn due to impending retirement of this measure |
| 316 | Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting LDL-C | 61v3 & 64v3 | - | 316 | Percentage of patients aged 20 through 79 years whose risk factors* have been assessed and a fasting LDL test has been performed AND percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal. *There are three criteria for this measure based on the patient’s risk category. 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent OR 10-Year Framingham Risk >20% 2. Moderate Level of Risk: Multiple (2+) Risk Factors OR 10-Year Framingham Risk 10-20% 3. Lowest Level of Risk: 0 or 1 Risk Factor OR 10-Year Framingham Risk <10% | Effective Clinical Care | Outcome | CMS | - | - | Cardiovascular | A -2016 | Not endorsed | Non-Endorsed/Planned Submission | Non-Endorsed/ No Plan to Submit | - | - | - | - | Measure is being re-tooled by Interagency Workgroup | Q1 - N/A Q2 - N/A |
| - | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | - | - | - | - | - | - | - | - | - | - | - | - | - | Non-Endorsed/ Planned Submission | - | - | - | - | Q2 - currently in Alpha Testing | Q2 - N/A |
| - | STS | ||||||||||||||||||||
| 43 | Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery | - | 0134 | 043 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft | Effective Clinical Care | Process | STS | - | - | Surgery | A -2016 | Endorsed | Full | Full | - | - | Q1 | 2016 (likely) | One exclusion slightly edited to provide clarification (to be submitted in annual update in April 2014) - "No LAD disease (or no bypassable LAD)" as acceptable reason for not using IMA | Q1-Annual update submitted 04/2014 Q2- no change |
| 164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation | - | 0129 | 164 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours | Effective Clinical Care | Outcome | STS | - | - | Surgery | A -2016 | Endorsed | Full | Full | - | - | Q4 | Currently undergoing review | Testing completed to prepare for submission to NQF | Q1-Annual update submitted 04/2014 Q2- no change |
| 165 | Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | - | 0130 | 165 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention | Effective Clinical Care | Outcome | STS | - | - | Surgery | A -2016 | Endorsed | Full | Full | - | - | Q4 | 2016 (likely) | N/A | Q1- no activity Q2- no change |
| 166 | Coronary Artery Bypass Graft (CABG): Stroke | - | 0131 | 166 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours | Effective Clinical Care | Outcome | STS | - | - | Surgery | A -2016 | Endorsed | Full | Full | - | - | Q4 | Currently undergoing review | Testing completed to prepare for submission to NQF | Q1-Measure currently being reviewed under NQF Surgery Project Q2- no change |
| 167 | Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | - | 0114 | 167 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis | Effective Clinical Care | Outcome | STS | - | - | Surgery | A -2016 | Endorsed | Full | Full | - | - | Q4 | Currently undergoing review | Testing completed to prepare for submission to NQF | Q1-Measure currently being reviewed under NQF Surgery Project Q2- no change |
| 168 | Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | - | 0115 | 168 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason | Effective Clinical Care | Outcome | STS | - | - | Surgery | A -2016 | Endorsed | Full | Full | - | - | Q4 | 2016 (likely) | N/A | Q1- no activity Q2- no change |
| 169 | Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge | - | 0116 | 169 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on antiplatelet medication | Effective Clinical Care | Process | STS | - | - | Surgery | A -2016 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | 2016 (likely) | Additional exclusion to be added in April 2014 - Acceptable to exclude from denominator if ADP inhibitor was contraindicated | Q1-Annual update submitted 04/2014 Q2- no change |
| 170 | Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge | - | 0117 | 170 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on beta-blockers | Effective Clinical Care | Process | STS | - | - | Surgery | A -2016 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q2 | 2016 (likely) | N/A | Q1- no activity Q2- no change |
| 171 | Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge | - | 0118 | 171 | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on a statin or other lipid-lowering regimen | Effective Clinical Care | Process | STS | - | - | Surgery | A -2016 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | 2016 (likely) | Per new 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, "other lipid-lowering regimen" will be removed from numerator in April 2014 | Q1-Annual update submitted 04/2014 Q2- no change |
| 157 | Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer Resection | - | 0455 | 157 | Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical staging provided prior to surgery | Patient Safety | Process | STS | - | - | Cancer | B - 2014 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | 2014 (likely) | N/A | Q1-Annual update submitted 04/2014 Q2- no change |
| 233 | Recording of Performance Status Prior to Lung or Esophageal Cancer Resection | - | 0457 | 233 | Percentage of patients aged 18 years and older undergoing resection for lung or esophageal cancer for whom performance status was documented and reviewed within 2 weeks prior to surgery | Effective Clinical Care | Process | STS | - | - | Cancer | B - 2014 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q1 | 2014 (likely) | N/A | Q1-Annual update submitted 04/2014 Q2- no change |
| 234 | Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection (Pneumonectomy, Lobectomy, or Formal Segmentectomy) | - | 0458 | 234 | Percentage of thoracic surgical patients aged 18 years and older undergoing at least one pulmonary function test within 12 months prior to a major lung resection (pneumonectomy, lobectomy, or formal segmentectomy) | Patient Safety | Process | STS | - | - | Surgery | A -2016 | Full-Endorsement | Full-Endorsement | Full-Endorsement | - | - | Q3 | Currently undergoing review | Testing completed to prepare for submission to NQF | Q1-Measure currently being reviewed under NQF Surgery Project Q2- no change |
| - | SVS | ||||||||||||||||||||
| 172 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 257 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 258 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 259 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 260 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 344 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 345 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 346 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
| 347 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - |
AMA measures
| PQRS # | |
| Measures Proposed for Removal Due to Lacking Steward that Later had a Steward Identified and thus were taken off the remove table | |
| 51 | (will be still listed as AMA since notice of new steward not received until after 8/15) |
| 52 | (will be still listed as AMA since notice of new steward not received until after 8/15) |
| 109 | |
| 147 | |
| 173 | |
| 276 | |
| 277 | |
| 278 | |
| 279 | |
| AMA measures that are still orphaned and thus will be removed from PQRS | |
| 142 | (CMS recommended removal due to this being a clinical concept that does not add clinical value in addition to it not having a steward) |
| 335 | |
| 336 | |
| AMA measures for which notification of a new steward was received after August 15th and thus will be listed as AMA in the Final Rule | |
| 51 | |
| 52 | |
| ABIM measures that are still orphaned and thus will be removed from PQRS | |
| 295 | |
| 296 | |
| 297 | (CMS also recommended removal due to this being a process measure that is distal to the outcome and has not been shown to improve patient outcomes) |
| 298 | |
| 299 | |
| 300 | |
| 302 | |
Excluded Included Notes
| Ex %username%: ○ Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life NQF 1516 measure is listed as a new included measure in QPP 2018 Final Rule (pdf pg 1393), not found in 2018 MIPS Rules spreadsheet. Include in data warehouse? Does not have Quality Measure # DO NOT INCLUDE IN MEASURE WAREHOUSE | Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life | N/A | 2018 | ??? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Inc %username%: Absent from original 2019 Data Warehouse, listed in proposed for inclusion in 2019 proposed rule, and present in 2018 and 2017 SHOULD be included in 2019, NOT removed | Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | CMS122v6 | N/A | 0059 | 001 | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period | Effective Clinical Care | Intermediate Outcome | Management of Chronic Conditions | X | - | National Committee for Quality Assurance | X | - | X | X | - | X | - | - | - | - | - | - | - | X | X | - | - | - | - | - | - | - | - | X | - | - | - | - | - | - | - | - | - | - | - | - | X | - | - | - | - | X | - | 2017 |
Needed Columns
| Measure Title | Measure # | Claims/Registry Measure Tag | eMeasure Specific Measure Tag** | Additional Analytic Logic or Guidance | Inverse | Non-Billable Codes in the Denominator | # of Perf Rates | Overall Perf Rate |
| Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 005 | Patient - Process / Visit | Patient-Based Measure | This measure has multiple denominator options based on care setting (outpatient vs. inpatient). This measure requires the reporting of only one data completeness and performance rate. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | 006 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 007 | Patient - Process | Patient-Based Measure | This measure has multiple denominator options based on diagnosis. This measure requires the reporting of two performance rates. An overall data completeness and performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall data completeness is determined by summing the data completeness numerator counts of each submeasure and dividing by the sum of the data completeness denominator counts of each submeasure. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. There are two reporting criteria for this measure: (1) Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% prescribed a beta blocker (2) Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have prior myocardial infarction prescribed a beta blocker For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 2 | Weighted Average |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 008 | Patient - Process / Visit | Patient-Based Measure | This measure has multiple denominator options based on care setting (outpatient vs. inpatient). This measure requires the reporting of only one data completeness and performance rate. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02.would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Anti-Depressant Medication Management | 009 | N/A | Patient-Based Measure | The eCQM measure requires that two performance rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months). An overall performance rate needs to be calculated for this measure. A simple average of the performance rates will be determined to calculate the overall performance rate. This is determined by adding the performance rate percentages for each submeasure and divide by the total number of component submeasures. | N | N | 2 | Simple Average |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 012 | Patient - Process | Patient-Based Measure | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 014 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy | 018 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 019 | Patient - Process | Patient-Based Measure | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | 021 | Procedure | N/A | N | N | 1 | N/A | |
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 023 | Procedure | N/A | N | N | 1 | N/A | |
| Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | 024 | Episode (TIN/NPI/Bene-level) | N/A | Claims: • Count each unique diagnosis as an episode for an TIN/NPI/Bene unless multiple diagnoses appear on the same claim. • Multiple qualifying ICD10, CPT or HCPC procedure on a single claim are counted once. (A single claim can be counted a maximum of once for an episode per TIN/NPI/Bene combo regardless of the number of qualifying DXs or procedures that exist). • Multiple claims with any intersecting diagnosis will be counted once. Intersecting claims with diagnosis codes will be counted once. All claims that share diagnosis codes are combined into one episode, given they have the same TIN/NPI/Bene. • If the TIN/NPI/Bene combo has multiple claims containing "different" qualifying DX codes that have not been submitted during the performance period, then these claims may each count as additional episodes. • Use the most favorable instance of reporting for performance rates if multiple conflicting QDCs exist on a qualifying episode • The QDC must exist on the claim with the qualifying denom episode (overarching rule for all measures) This measure has multiple denominator options based on care setting (outpatient vs. procedure). This measure requires the reporting of only one data completeness and performance rate. | N | N | 1 | N/A |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 039 | Patient - Process | N/A | Diagnosis of osteoporosis on the date of service is not considered denominator eligible. | N | N | 1 | N/A |
| Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery | 043 | Procedure: use Episode logic | N/A | N | N | 1 | N/A | |
| Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | 044 | Procedure | N/A | N | N | 1 | N/A | |
| Medication Reconciliation Post-Discharge | 046 | Episode (Regardless of TIN/NPI) | N/A | This measure requires the reporting of three performance rates. The third performance rate outlined in the measure specification should be utilized for an overall reporting and performance rate for this measure. Claims: • Age must be >= to 18 on the outpt visit date. • If med reconciliation is reported > once for an inpt discharge (utilizing Part B claims), the most favorable QDC(s) reported w/in 30 days after the discharge should count for the episode for performance calculations. • The 30 day episode will start 30 days minus the 1st expense date of an outpt visit where a denom code is present on the claim’s line item. If multiple outpt visits appear (where denom codes are on multiple line items) on the same claim take the denom code line item with the latest expense date (of the denom codes that fall within 30-days of the inpt. discharge on that claim). • Hospital (inpt Part B discharge) "hidden" codes are at the bene-level regardless of TIN/NPI. Correlate eligible cases with non-denom inpt codes for bene regardless of TIN/NPI to find last inpt expense date, then count 30 days per episode from that date. • Inpt discharges may occur up to 30 days prior to the beginning of the performance period (January 1, 2017), but outpt visits must occur during the reporting period (January 1 - December 31, 2017). • Take the last inpt expense date of the line item for the relevant “hidden” inpatient codes when multiple inpt codes are submitted on consecutive days or when one inpt code spans several expense dates, the last date should count as the date of inpt discharge. • The last inpt discharge during the 30 day episode will override any previous inpt discharges. • If the outpatient visit occurs during the hospital visit (same day as an inpatient code is submitted), then it will not count as an instance of reporting. An outpatient visit must occur at least one day AFTER an inpatient discharge (break in inpatient codes) to count as an instance of reporting. • REFER TO THE "HIDDEN CODES" TAB OF THE SINGLE SOURCE FOR A COMPLETE LISTING OF THE HOSPITAL INPATIENT DISCHARGE "HIDDEN" CODES. | N | N | 3 | 3rd Performance Rate |
| Advanced Care Plan | 047 | Patient - Process | N/A | Claims: Exclude line items from the denominator when CPT codes are seen with a Place of Service (POS) = 23. | N | N | 1 | N/A |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 048 | Patient - Process | N/A | N | N | 1 | N/A | |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 050 | Patient - Process | N/A | N | N | 1 | N/A | |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 051 | Patient - Intermediate | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 052 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 065 | Episode (TIN/NPI/Bene-level) | Episode-of-Care Measure | N | N | 1 | N/A | |
| Appropriate Testing for Children with Pharyngitis | 066 | Episode (TIN/NPI/Bene-level) | Episode-of-Care Measure | N | Y | 1 | N/A | |
| Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | 067 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | 068 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Hematology: Multiple Myeloma: Treatment with Bisphosphonates | 069 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | 070 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 076 | Procedure | N/A | N | N | 1 | N/A | |
| Acute Otitis Externa (AOE): Topical Therapy | 091 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Approved to count an episode as any claims for the TIN/NPI/Bene that qualify for the measure within a 30-day timeframe. Use the last expense date corresponding to qualifying line items (denominator dx or encounter codes) on the first claim to start the 30-day episode. The 30-day continues forward to include any subsequent claim(s) where the 1st expense date on qualifying line items (denominator dx or procedure codes) is within 30-days of the last expense date on that 1st claim. The first claim with a QDC within the episode is the QDC to use when calculating performance . For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | 093 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Approved to count an episode as any claims for the TIN/NPI/Bene that qualify for the measure within a 30-day timeframe. Use the last expense date corresponding to qualifying line items (denominator dx or encounter codes) on the first claim to start the 30-day episode. The 30-day continues forward to include any subsequent claim(s) where the 1st expense date on qualifying line items (denominator dx or procedure codes) is within 30-days of the last expense date on that 1st claim. The first claim with a QDC within the episode is the QDC to use when calculating performance. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | 099 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | 100 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | Episode (Regardless of TIN/NPI) | Patient-Based Measure | N | N | 1 | N/A | |
| Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | 104 | Episode (Regardless of TIN/NPI) | N/A | N | N | 1 | N/A | |
| Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 107 | N/A | Episode-of-Care Measure | N | N | 1 | N/A | |
| Osteoarthritis (OA): Function and Pain Assessment | 109 | Visit | N/A | N | N | 1 | N/A | |
| Preventive Care and Screening: Influenza Immunization | 110 | Patient - Periodic | Patient-Based Measure | Report a minimum of once for visits occurring between January 1, 2017 and March 31, 2017 for the 2016-2017 influenza season and a minimum of once for visits occurring between October 1, 2017 and December 31, 2017 for the 2017-2018 influenza season. For example, if there is a visit in January 2017 and a visit in November 2017, both of these visits would count in the denominator (a count of 2). However, if there are two visits which occur in January 2017 and one in February 2017, only one of these needs to be reported to account for the 2016-2017 influenza season. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Pneumococcal Vaccination Status for Older Adults | 111 | Patient - Process | Patient-Based Measure | N | N | 1 | N/A | |
| Breast Cancer Screening | 112 | Patient - Process | Patient-Based Measure | The measure has a denominator of women 50 to 74 years of age with a visit during the performance period. This is to ensure that the patient sample maintains the proper age criteria within the performance period. Therefore, women ages 50-52 are included in the measure if they had a visit and a mammogram since age 50, but the look back only applies to patients age 52-74. | N | N | 1 | N/A |
| Colorectal Cancer Screening | 113 | Patient - Process | Patient-Based Measure | The measure has a denominator of 51-75 to capture all adults at least 50 years of age and older who may have had a screening. This is to ensure that the patient sample maintains an age criteria of 50 years of age within the performance period. | N | N | 1 | N/A |
| Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | 116 | Episode (TIN/NPI/Bene- level) | N/A | Y | N | 1 | N/A | |
| Diabetes: Eye Exam | 117 | Patient - Process | Patient-Based Measure | N | N | 1 | N/A | |
| Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 118 | Patient - Process | N/A | The measure has multiple denominator options based on diagnosis. This measure requires the reporting of only one data completeness and performance rate. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Diabetes: Medical Attention for Nephropathy | 119 | Patient - Process | Patient-Based Measure | N | N | 1 | N/A | |
| Adult Kidney Disease: Blood Pressure Management | 122 | Visit | N/A | This measure has multiple denominator options. This measure requires the reporting of three performance rates. The third performance rate outlined in the measure specification should be utilized for an overall data completeness and performance rate for this measure. This measure will be calculated with 3 performance rates: 1) Percentage of patient visits with blood pressure results < 140/90 mmHg 2) Percentage of patient visits with blood pressure results ≥ 140/90 mmHg and plan of care 3) Overall percentage of patient visits with blood pressure results < 140/90 mmHg and ≥ 140/90 mmHg with a documented plan of care For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 3 | 3rd Performance Rate |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | 126 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | 127 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Patient - Intermediate | Patient-Based Measure | Claims: When a QDC is reported for an eligible patient during the performance period, use the most recent (the last) qualifying claim WITH a QDC reported during the performance period. Determine most recent by date of service for QDCs submitted. • The BMI can be calculated either within the prior 6 months of the current qualifying visit OR calculated during the current qualifying visit, during measurement period. The BMI documented in the medical record may be reported if done in the provider’s office/facility or if a BMI is documented within the previous six months in outside medical records obtained by the provider. eHR: The eCQM measure requires the reporting of two performance rates. An overall performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02.would not be considered encounter (eligible cases). | N | Y | Claims/ Registry = 1 eCQM = 2 | eCQM = Weighted Average |
| Documentation of Current Medications in the Medical Record | 130 | Visit | Episode-of-Care Measure | N | Y | 1 | N/A | |
| Pain Assessment and Follow-Up | 131 | Visit | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | Patient - Process | Patient-Based Measure | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Melanoma: Continuity of Care – Recall System | 137 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Melanoma: Coordination of Care | 138 | Visit | N/A | This measure has multiple denominator options. This measure requires the reporting of only one data completeness and performance rate. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement | 140 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Oncology: Medical and Radiation – Pain Intensity Quantified | 143 | Visit | Episode-of-Care Measure | No requirement exists to report both measures (143 and 144) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Oncology: Medical and Radiation – Plan of Care for Pain | 144 | Visit | N/A | No requirement exists to report both measures (143 and 144) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | Procedure | N/A | N | Y | 1 | N/A | |
| Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms | 146 | Procedure | N/A | Performance hierarchy is reversed to determine the most favorable instance of reporting for performance rate calculations (fails performance then meets performance) - used when multiple QDCs are reported on the same claim/day. | Y | Y | 1 | N/A |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Procedure | N/A | N | N | 1 | N/A | |
| Falls: Risk Assessment | 154 | Patient - Process | N/A | No requirement exists to report both measures (154 and 155) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. | N | N | 1 | N/A |
| Falls: Plan of Care | 155 | Patient - Process | N/A | Denominator coding is CPT II code 1100F (without a 1P, 2P, 3P or 8P modifier) AND encounter codes from measure 154. No requirement exists to report both measures (154 and 155) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. | N | N | 1 | N/A |
| Oncology: Radiation Dose Limits to Normal Tissues | 156 | Patient - Process | N/A | N | N | 1 | N/A | |
| HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | 160 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of three performance rates. An overall performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. | N | Y | 3 | Weighted Average |
| Diabetes: Foot Exam | 163 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | Procedure | N/A | Y | N | 1 | N/A | |
| Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | 165 | Procedure | N/A | Y | N | 1 | N/A | |
| Coronary Artery Bypass Graft (CABG): Stroke | 166 | Procedure | N/A | Y | N | 1 | N/A | |
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | Procedure | N/A | Y | N | 1 | N/A | |
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | Procedure | N/A | Y | N | 1 | N/A | |
| Rheumatoid Arthritis (RA): Tuberculosis Screening | 176 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02.would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | 179 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Functional Outcome Assessment | 182 | Visit | N/A | N | N | 1 | N/A | |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | 185 | Procedure | N/A | CPT codes 44388, 44389, 44392, 44394, 45378, 45380, 45381, 45384, 45385 that has a modifier 52, 53, 73 or 74 are not to be included in the eligible denominator. Modifiers not relevant for G0105, because CPT I modifiers do not apply to G-codes. | N | N | 1 | N/A |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | Procedure | Episode-of-Care Measure | Include only procedures performed through September 30th of the performance period. This will allow the post-operative period to occur within the performance period. For denominator criteria, patients who meet criteria but with Modifier 56 or 55 would not meet denominator criteria. | N | N | 1 | N/A |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | Procedure | Episode-of-Care Measure | For denominator criteria, patients who meet criteria but with Modifier 56 or 55 would not meet denominator criteria. | Y | N | 1 | N/A |
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Procedure | N/A | N | N | 1 | N/A | |
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | Patient - Process | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Knee Impairments | 217 | Episode | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Hip Impairments | 218 | Episode | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Foot or Ankle Impairments | 219 | Episode | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Lumbar Impairments | 220 | Episode | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Shoulder Impairments | 221 | Episode | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | Episode | N/A | N | N | 1 | N/A | |
| Functional Status Change for Patients with Other General Orthopaedic Impairments | 223 | Episode | N/A | N | N | 1 | N/A | |
| Melanoma: Avoidance of Overutilization of Imaging Studies | 224 | Patient - Process | N/A | The measure has multiple denominator options. This measure requires the reporting of only one reporting and performance rate. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Radiology: Reminder System for Screening Mammograms | 225 | Procedure | N/A | N | N | 1 | N/A | |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Patient - Process | Patient-Based Measure | This measure has multiple performance rates. There are three submission criteria for this measure: 1. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months 2. Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention 3. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 3 | 2nd Performance Rate |
| Controlling High Blood Pressure | 236 | Patient - Intermediate | Patient-Based Measure | Claims: To describe both systolic and diastolic blood pressure values, each must be reported separately. • When a QDC is reported for an eligible patient during the performance period, use the most recent (the last) qualifying claim WITH a QDC reported during the performance period. Determine "most recent" by date of service of the QDCs submitted. This date should have the same date of service for both QDCs required in performance calculations. | N | N | 1 | N/A |
| Use of High-Risk Medications in the Elderly | 238 | Patient - Process | Patient-Based Measure | This measure has multiple denominator options. This measure requires the reporting of two performance rates. The first performance rate (Percentage of patients who were ordered at least one high-risk medication) defined in the measure will be utilized as the overall data completeness and performance rate for this measure. | Y | N | 2 | 1st Performance Rate |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 239 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of three performance rates. An overall performance rate needs to be calculated for this measure. A simple average of the performance rates will be determined to calculate the overall performance rate. This is determined by adding the performance rate percentages for each submeasure and divide by the total number of component submeasures. | N | N | 3 | Simple Average |
| Childhood Immunization Status | 240 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Barrett's Esophagus | 249 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Radical Prostatectomy Pathology Reporting | 250 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | 251 | Procedure | N/A | Claims: The measure should be reported each time a quantitative HER2 IHC pathology examination is performed during the performance period for patients with breast cancer; however, only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Use episode logic even though it does not match instructions in specifications Counted once per claim for each TIN/NPI/Bene • Multiple ICD10- codes on a single claim count once. • These will be treated as episode measures with no special coding required. • Line items with CPT I coding require a place of service code "23" to be included in the denominator. | N | N | 1 | N/A |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Use episode logic even though it does not match instructions in specifications Counted once per claim for each TIN/NPI/Bene • Multiple ICD10 codes on a single claim count once. • These will be treated as episode measures with no special coding required. • Line items with CPT I coding require a place of service code "23" to be included in the denominator. | N | N | 1 | N/A |
| Statin Therapy at Discharge after Lower Extremity Bypass (LEB) | 257 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | 258 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | 259 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | Procedure | N/A | N | N | 1 | N/A | |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Patient - Process | N/A | N | N | 1 | N/A | |
| Image Confirmation of Successful Excision of Image-Localized Breast Lesion | 262 | Procedure | N/A | N | N | 1 | N/A | |
| Preoperative Diagnosis of Breast Cancer | 263 | Procedure | N/A | N | N | 1 | N/A | |
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | Procedure | N/A | N | N | 1 | N/A | |
| Biopsy Follow-Up | 265 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | 271 | Patient - Process | N/A | N | N | 1 | N/A | |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | Patient - Process | N/A | N | N | 1 | N/A | |
| Sleep Apnea: Assessment of Sleep Symptoms | 276 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Sleep Apnea: Severity Assessment at Initial Diagnosis | 277 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Sleep Apnea: Positive Airway Pressure Therapy Prescribed | 278 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | 279 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia: Cognitive Assessment | 281 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Dementia: Functional Status Assessment | 282 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | 283 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia | 286 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia: Caregiver Education and Support | 288 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease | 290 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment | 291 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Parkinson’s Disease: Rehabilitative Therapy Options | 293 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | 303 | Procedure | N/A | · Only procedures performed through September 30 of the performance period are eligible for the denominator. This will allow the post- operative period to occur before registries must submit data to CMS. For denominator criteria, modifier 56 or 55 would be excluded from the denominator. | N | N | 1 | N/A |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | Procedure | N/A | · Only procedures performed through September 30 of the performance period are eligible for the denominator. This will allow the post- operative period to occur before registries must submit data to CMS. For denominator criteria, modifier 56 or 55 would be excluded from the denominator. | N | N | 1 | N/A |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of two performance rates. An overall performance rate needs to be calculated for this measure. A simple average of the performance rates will be determined to calculate the overall performance rate. This is determined by adding the performance rate percentages for each submeasure and divide by the total number of component submeasures. | N | N | 2 | Simple Average |
| Cervical Cancer Screening | 309 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Chlamydia Screening for Women | 310 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Patient - Process | Patient-Based Measure | N | Y | 1 | N/A | |
| Falls: Screening for Future Fall Risk | 318 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Patient - Process | N/A | Denominator eligible CPT codes 44388, 45378 submitted with a modifier 52, 53, 73, and 74 should be excluded from the denominator for claims or excluded by the registry. If QDCs are submitted on the same claim for multiple measures, exclude only the line item with the modifier. Modifiers not relevant for G0121, because CPT I modifiers do not apply to G-codes. | N | N | 1 | N/A |
| CAHPS for MIPs Clinician/Group Survey | 321 | |||||||
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | 322 | Procedure | N/A | Y | N | 1 | N/A | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | 323 | Procedure | N/A | Y | N | 1 | N/A | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | 324 | Procedure | N/A | Y | N | 1 | N/A | |
| Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | 325 | Patient - Process | N/A | N | N | 1 | N/A | |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Pediatric Kidney Disease: Adequacy of Volume Management | 327 | Patient - Periodic | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL | 328 | Patient - Periodic | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | 329 | Patient - Process | N/A | No requirement exists to report both measures (329 and 330) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | 330 | Patient - Process | N/A | No requirement exists to report both measures (329 and 330) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | 333 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | 334 | Visit | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse) | 335 | Procedure | N/A | N | N | 1 | N/A | |
| Maternity Care: Post-Partum Follow-Up and Care Coordination | 336 | Patient - Process | N/A | N | N | 1 | N/A | |
| Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier | 337 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| HIV Viral Load Suppression | 338 | Patient - Process | N/A | N | N | 1 | N/A | |
| HIV Medical Visit Frequency | 340 | Patient - Process | N/A | N | N | 1 | N/A | |
| Pain Brought Under Control Within 48 Hours | 342 | Patient - Process | N/A | N | N | 1 | N/A | |
| Screening Colonoscopy Adenoma Detection Rate | 343 | Procedure | N/A | CPT codes 45378, 45380, 45381, 45384, 45385, 45380 that has a modifier 52, 53, 73 or 74 are not to be included in the eligible denominator. Modifiers not relevant for G0121, because CPT I modifiers do not apply to G-codes. | N | N | 1 | N/A |
| Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | 344 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive | 345 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive | 346 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive | 347 | Procedure | N/A | N | N | 1 | N/A | |
| HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | 348 | Patient - Process | N/A | An overall data completeness and performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall data completeness is determined by summing the data completeness numerator counts of each submeasure and dividing by the sum of the data completeness denominator counts of each submeasure. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. There are 2 performance rates to be calculated for this measure: 1. Complications or mortality at 30 days OR 2. Complications at 90 days | Y | N | 2 | Weighted Average |
| Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | 350 | Procedure | N/A | N | N | 1 | N/A | |
| Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | 351 | Procedure | N/A | N | N | 1 | N/A | |
| Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | 352 | Procedure | N/A | N | N | 1 | N/A | |
| Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | 353 | Procedure | N/A | N | N | 1 | N/A | |
| Anastomotic Leak Intervention | 354 | Procedure | N/A | Y | N | 1 | N/A | |
| Unplanned Reoperation within the 30 Day Postoperative Period | 355 | Procedure | N/A | Y | N | 1 | N/A | |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | 356 | Procedure | N/A | Y | N | 1 | N/A | |
| Surgical Site Infection (SSI) | 357 | Procedure | N/A | Y | N | 1 | N/A | |
| Patient-Centered Surgical Risk Assessment and Communication | 358 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | 359 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | 360 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | 361 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison | 362 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive | 363 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 364 | Procedure | N/A | N | N | 1 | N/A | |
| Follow-Up Care for Children Prescribed ADHD Medication (ADD) | 366 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of two performance rates (Intake & Continuation and Maintenance Phase). An overall performance rate needs to be calculated for this measure. A simple average of the performance rates will be determined to calculate the overall performance rate. This is determined by adding the performance rate percentages for each submeasure and divide by the total number of component submeasures. | N | N | 2 | Simple Average |
| Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use | 367 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Depression Remission at Twelve Months | 370 | Patient - Process | Patient-Based Measure | NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and a PHQ-9 Score greater than 9 documented on the same date (index event) and this date occurs during denominator identification period (11/1/2016 to 10/31/2017). Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis. | N | N | 1 | N/A |
| Depression Utilization of the PHQ-9 Tool | 371 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of three performance rates. An overall performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. | N | N | 3 | Weighted Average |
| Maternal Depression Screening | 372 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Hypertension: Improvement in Blood Pressure | 373 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | Patient - Process | Patient-Based Measure | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Functional Status Assessment for Total Knee Replacement | 375 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Functional Status Assessment for Total Hip Replacement | 376 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Functional Status Assessments for Congestive Heart Failure | 377 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Children Who Have Dental Decay or Cavities | 378 | N/A | Patient-Based Measure | Y | N | 1 | N/A | |
| Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 379 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | N/A | Episode-of-Care Measure | N | N | 1 | N/A | |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | Patient - Process | N/A | N | Y | 1 | N/A | |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | Procedure | N/A | N | N | 1 | N/A | |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | Procedure | N/A | N | N | 1 | N/A | |
| Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | 386 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | 387 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) | 388 | Procedure | N/A | Y | N | 1 | N/A | |
| Cataract Surgery: Difference Between Planned and Final Refraction | 389 | Procedure | N/A | N | N | 1 | N/A | |
| Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | 390 | Patient - Process | N/A | N | N | 1 | N/A | |
| Follow-Up After Hospitalization for Mental Illness (FUH) | 391 | Visit | N/A | The measure has multiple denominator options. Acute inpatient setting discharges between January 1st and December 1st of the measurement period is one of the denominator criteria. This measure requires the reporting of two performance rates. The second performance rate (Percentage of discharges for which patient received follow-up within 7 days of discharge) defined in the measure will be utilized as the overall data completeness and performance rate for this measure. This measure requires the reporting of two performance rates. (1) Percentage of discharges for which the patient received follow-up within 30 days of discharge. (2) Percentage of discharges for which the patient received follow-up within 7 days of discharge. | N | N | 2 | 2nd Performance Rate |
| HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | 392 | Patient - Process | N/A | This measure has multiple denominator options. This measure requires the reporting of five performance rates but only one data completeness is required. The fifth performance rate outlined below should be utilized for an overall data completeness and performance rate for this measure. This measure requires the reporting of five performance rates. 1) Females less than 65 years of age 2) Males less than 65 years of age 3) Females 65 years of age and older 4) Males 65 years of age and older 5) Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days | Y | N | 5 | 5th Performance Rate |
| HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | 393 | Patient - Process | N/A | This measure requires the reporting of only one data completeness and performance rate. There are two reporting criteria for this measure: 1) Patients, regardless of age, with a new CIED OR 2) Patients, regardless of age, with a replaced or revised CIED | Y | N | 1 | N/A |
| Immunizations for Adolescents | 394 | Patient - Process | N/A | This measure requires the reporting of four performance rates. The third performance rate outlined below should be utilized for an overall data completeness and performance rate for this measure. This measure will be calculated with 4 performance rates: 1) Patients who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays 2) Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the patient’s 10th and 13th birthdays 3) Patients who had at least three HPV vaccines with different dates of service on or between the patient's 9th and 13th birthdays 4) All patients who are compliant for both Meningococcal AND Td/Tdap AND HPV during the specified timeframes. | N | N | 4 | 4th Performance Rate |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Lung Cancer Reporting (Resection Specimens) | 396 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Melanoma Reporting | 397 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Optimal Asthma Control | 398 | Patient - Process | N/A | The measure has multiple denominator options. This measure requires the reporting of seven performance rates. The first performance rate outlined below should be utilized for an overall data completeness and performance rate for this measure. This measure should be calculated with 7 performance rates: 1. Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation. 2. Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation. 3. Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation. 4. Asthma well-controlled (take the most recent ACT) for patients 5 to 17 with Asthma 5. Asthma well-controlled (take the most recent ACT) for patients 18 to 50 with Asthma 6. Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma 7. Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma | N | N | 7 | 1st Performance Rate |
| One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | 400 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | Patient - Process | N/A | N | N | 1 | N/A | |
| Tobacco Use and Help with Quitting Among Adolescents | 402 | Patient - Process | N/A | N | N | 1 | N/A | |
| Adult Kidney Disease: Referral to Hospice | 403 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Anesthesiology Smoking Abstinence | 404 | Procedure (Regardless of TIN/NPI) | N/A | N | N | 1 | N/A | |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Procedure | N/A | Y | N | 1 | N/A | |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Procedure | N/A | Y | N | 1 | N/A | |
| Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | 407 | Episode (Regardless of TIN/NPI) | N/A | Claims: Utilize Part B Claims. Correlate eligible cases with inpatient "hidden" codes at the bene-level regardless of TIN/NPI to determine the length of hospital stay (episode). "Hidden" inpatient code line items that are denied or include modifier 80, 81 or 82 should be included in this analysis. •REFER TO THE "HIDDEN CODES" TAB OF THE SINGLE SOURCE FOR A COMPLETE LISTING OF CPT I INPATIENT "HIDDEN" CODES • Inpatient "hidden" CPT I codes are counted once per hospital stay • Multiple ICD10 codes on the same claim are counted once • Maximum one episode per claim (even if there is a break in DOS for inpatient "hidden" CPT I codes on that claim) • Count any inpatient "hidden" CPT I in a string of consecutive DOS at bene level for all TIN/NPI as one episode • Look across claims to determine the episode based on "consecutive dates of service," use the earliest DOS for an inpatient "hidden" CPT I code and the latest DOS for an inpatient "hidden" CPT I code on each claim to identify claims with consecutive DOS. • Most favorable instance of reporting is used in performance rate | N | N | 1 | N/A |
| Opioid Therapy Follow-up Evaluation | 408 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Clinical Outcome Post Endovascular Stroke Treatment | 409 | Procedure | N/A | NOTE: Include only patients that have cerebrovascular accidents through September 30 of the performance period. This will allow the evaluation of at least 90 days after the cerebrovascular accident within the performance period. | N | N | 1 | N/A |
| Psoriasis: Clinical Response to Systemic Medications | 410 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Depression Remission at Six Months | 411 | Patient - Process | N/A | NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and a PHQ-9 Score greater than 9 documented on the same date (index event) and this date occurs during the denominator identification measurement period (11/1/2016 to 10/31/2017). Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis. | N | N | 1 | N/A |
| Documentation of Signed Opioid Treatment Agreement | 412 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Door to Puncture Time for Endovascular Stroke Treatment | 413 | Procedure | N/A | N | N | 1 | N/A | |
| Evaluation or Interview for Risk of Opioid Misuse | 414 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | Visit | N/A | Claims: The patient should have CPT 70450 (regardless of TIN/NPI) on the same date of service as the denominator eligible encounter in order to be included in the denominator. | N | N | 1 | N/A |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Visit | N/A | Claims: The patient should have CPT 70450 (regardless of TIN/NPI) on the same date of service as the denominator eligible encounter in order to be included in the denominator. | Y | N | 1 | N/A |
| Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive | 417 | Procedure | N/A | N | N | 1 | N/A | |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Count each unique diagnosis as an episode for an TIN/NPI/Bene unless multiple diagnoses appear on the same claim. • Multiple qualifying ICD10 or CPT I procedures on a single claim are counted once. (A single claim can be counted a maximum of once for an episode per TIN/NPI/Bene combo regardless of the number of qualifying DXs or procedures that exist.) • Multiple claims with any intersecting diagnosis will be counted once. Intersecting claims with diagnosis codes will be counted once. All claims that share diagnosis codes are combined into one episode, given they have the same TIN/NPI/Bene • If the TIN/NPI/Bene combo has multiple claims containing *different* qualifying DX codes that have not been submitted during the performance period, then these claims may each count as additional episodes. • Use the most favorable instance of reporting for performance rates if multiple conflicting QDCs exist on a qualifying episode. • The QDC must exist on the claim with the qualifying denom episode (overarching rule for all measures). | N | N | 1 | N/A |
| Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination | 419 | Visit | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | 420 | Procedure | N/A | N | N | 1 | N/A | |
| Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | 421 | Procedure | N/A | N | N | 1 | N/A | |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Procedure | N/A | N | N | 1 | N/A | |
| Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy | 423 | Procedure | N/A | N | N | 1 | N/A | |
| Perioperative Temperature Management | 424 | Procedure | N/A | N | N | 1 | N/A | |
| Photodocumentation of Cecal Intubation | 425 | Procedure | N/A | Denominator eligible CPT codes submitted with a modifier 73 and 74 should be excluded from the denominator for claims or excluded by the registry. If QDCs are submitted on the same claim for multiple measures, exclude only the line item with the modifier. | N | N | 1 | N/A |
| Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) | 426 | Procedure | N/A | N | N | 1 | N/A | |
| Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) | 427 | Procedure | N/A | N | N | 1 | N/A | |
| Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | 428 | Procedure | N/A | N | N | 1 | N/A | |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Procedure | N/A | N | N | 1 | N/A | |
| Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | 430 | Procedure | N/A | N | N | 1 | N/A | |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | 432 | Procedure | N/A | Y | N | 1 | N/A | |
| Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 433 | Procedure | N/A | Y | N | 1 | N/A | |
| Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair | 434 | Procedure | N/A | Y | N | 1 | N/A | |
| Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Patient - Intermediate | N/A | Claims: Two denominator eligible visits for the same TIN/NPI with two different dates of service are required to be denominator eligible. The QDC needs to be reported on the 2nd visit (based on date of service) or a subsequent visit if more than two visits are found within the reporting period. A QDC submitted on the first visit (based on date of service) in the reporting period will not be counted. The most advantageous QDC should be utilized if multiple QDCs are submitted on any visit but the first visit within the reporting period. For the numerator, quality of life assessments with MIDAS must be separated by at least 90 days (4 weeks for any other tool). For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Procedure | N/A | N | Y | 1 | N/A | |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Procedure | N/A | Include only patients undergoing an endovascular lower extremity revascularization procedure through December 29 of the reporting period. This will allow the evaluation of at least 48 hours of the procedure within the reporting year. | Y | N | 1 | N/A |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | Patient - Process | N/A | The measure has multiple reporting criteria. This measure requires the reporting of only one reporting and performance rate. All considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: 1. Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR 2. Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR 3. Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Age Appropriate Screening Colonoscopy | 439 | Procedure | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician | 440 | Procedure | N/A | N | N | 1 | N/A | |
| Persistence of Beta-Blocker Treatment After a Heart Attack | 442 | Patient - Process | N/A | N | N | 1 | N/A | |
| Non-Recommended Cervical Cancer Screening in Adolescent Females | 443 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Medication Management for People with Asthma | 444 | Patient - Process | N/A | N | Y | 1 | N/A | |
| Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | 445 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Operative Mortality Stratified by the Five STS-EACTS Mortality Categories | 446 | Procedure | N/A | There are two reporting criteria for this measure and one performance rate. | Y | N | 1 | N/A |
| Chlamydia Screening and Follow Up | 447 | Patient - Process | N/A | N | Y | 1 | N/A | |
| Appropriate Work Up Prior to Endometrial Ablation | 448 | Procedure | N/A | N | Y | 1 | N/A | |
| HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies | 449 | Patient - Intermediate | N/A | N | N | 1 | N/A | |
| Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy | 450 | Patient - Intermediate | N/A | N | N | 1 | N/A | |
| RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | 451 | Patient - Process | N/A | N | N | 1 | N/A | |
| Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | 452 | Patient - Process | N/A | N | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better) | 453 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life (lower score - better) | 454 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better) | 455 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Not Admitted To Hospice (lower score - better) | 456 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better) | 457 | Patient - Process | Y | N | 1 | N/A | ||
| All-cause Hospital Readmission | 458 | |||||||
| Average Change in Back Pain following Lumbar Discectomy / Laminotomy | 459 | Visit | N/A | N | Y | 2 | 1st Performance Rate | |
| Average Change in Back Pain following Lumbar Fusion | 460 | Visit | N/A | N | Y | 2 | 1st Performance Rate | |
| Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy | 461 | Visit | N/A | N | Y | 2 | 1st Performance Rate | |
| Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | 462 | N/A | N/A | N | N | 1 | N/A | |
| Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | 463 | Procedure | N/A | N | Y | 1 | N/A | |
| Otitis Media with Effusion: Systemic Antimicrobials- Avoidance of Inappropriate Use | 464 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | 465 | Procedure | N/A | N | N | 1 | N/A | |
| Developmental Screening in the First Three Years of Life | 467 | Visit | N/A | The intent of this measure is to calculate a Total Performance Rate based on all children who turned 1, 2, or 3 during the performance period who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday, i.e., the sum of denominators 1, 2, and 3. There are three submission criteria for this measure and a total performance rate that is the sum of the three submission criteria.1) Children in the eligible population who turned 1 during the performance period. (Birth to 1 year of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday OR 2) Children in the eligible population who turned 2 during the performance period (> 1 year to 2 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday OR 3) Children in the eligible population who turned 3 during the performance period ( > 2 years to 3 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday 4. The total performance rate is calcuated calculated as the sum of Performance for criteria 1, 2 and 3. | N | N | 4 | 4th total performance rate |
| Continuity of Pharmacotherapy for Opioid Use Disorder | MUC17-139 (Quality) | |||||||
| Average change in functional status following lumbar spine fusion surgery | MUC17-168 (Quality) | |||||||
| Average change in functional status following total knee replacement surgery | MUC17-169 (Quality) | |||||||
| Average change in functional status following lumbar discectomy laminotomy surgery | MUC17-170 (Quality) | |||||||
| Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | MUC17-173 (Quality) | |||||||
| Average change in leg pain following lumbar spine fusion surgery | MUC17-177 (Quality) | |||||||
| Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication | MUC17-234 (Quality) | |||||||
| Zoster (Shingles) Vaccination | MUC17-310 (Quality) | |||||||
| HIV Screening | MUC17-367 (Quality) | |||||||
| Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls |
Needed Columns 2
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Barrett's Esophagus | 249 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Radical Prostatectomy Pathology Reporting | 250 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | 251 | Procedure | N/A | Claims: The measure should be reported each time a quantitative HER2 IHC pathology examination is performed during the performance period for patients with breast cancer; however, only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Use episode logic even though it does not match instructions in specifications Counted once per claim for each TIN/NPI/Bene • Multiple ICD10- codes on a single claim count once. • These will be treated as episode measures with no special coding required. • Line items with CPT I coding require a place of service code "23" to be included in the denominator. | N | N | 1 | N/A |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Use episode logic even though it does not match instructions in specifications Counted once per claim for each TIN/NPI/Bene • Multiple ICD10 codes on a single claim count once. • These will be treated as episode measures with no special coding required. • Line items with CPT I coding require a place of service code "23" to be included in the denominator. | N | N | 1 | N/A |
| Statin Therapy at Discharge after Lower Extremity Bypass (LEB) | 257 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | 258 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | 259 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | Procedure | N/A | N | N | 1 | N/A | |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Patient - Process | N/A | N | N | 1 | N/A | |
| Image Confirmation of Successful Excision of Image-Localized Breast Lesion | 262 | Procedure | N/A | N | N | 1 | N/A | |
| Preoperative Diagnosis of Breast Cancer | 263 | Procedure | N/A | N | N | 1 | N/A | |
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | Procedure | N/A | N | N | 1 | N/A | |
| Biopsy Follow-Up | 265 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | 271 | Patient - Process | N/A | N | N | 1 | N/A | |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | Patient - Process | N/A | N | N | 1 | N/A | |
| Sleep Apnea: Assessment of Sleep Symptoms | 276 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Sleep Apnea: Severity Assessment at Initial Diagnosis | 277 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Sleep Apnea: Positive Airway Pressure Therapy Prescribed | 278 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | 279 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia: Cognitive Assessment | 281 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Dementia: Functional Status Assessment | 282 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | 283 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia | 286 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Dementia: Caregiver Education and Support | 288 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease | 290 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment | 291 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Parkinson’s Disease: Rehabilitative Therapy Options | 293 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | 303 | Procedure | N/A | · Only procedures performed through September 30 of the performance period are eligible for the denominator. This will allow the post- operative period to occur before registries must submit data to CMS. For denominator criteria, modifier 56 or 55 would be excluded from the denominator. | N | N | 1 | N/A |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | Procedure | N/A | · Only procedures performed through September 30 of the performance period are eligible for the denominator. This will allow the post- operative period to occur before registries must submit data to CMS. For denominator criteria, modifier 56 or 55 would be excluded from the denominator. | N | N | 1 | N/A |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of two performance rates. An overall performance rate needs to be calculated for this measure. A simple average of the performance rates will be determined to calculate the overall performance rate. This is determined by adding the performance rate percentages for each submeasure and divide by the total number of component submeasures. | N | N | 2 | Simple Average |
| Cervical Cancer Screening | 309 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Chlamydia Screening for Women | 310 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Patient - Process | Patient-Based Measure | N | Y | 1 | N/A | |
| Falls: Screening for Future Fall Risk | 318 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Patient - Process | N/A | Denominator eligible CPT codes 44388, 45378 submitted with a modifier 52, 53, 73, and 74 should be excluded from the denominator for claims or excluded by the registry. If QDCs are submitted on the same claim for multiple measures, exclude only the line item with the modifier. Modifiers not relevant for G0121, because CPT I modifiers do not apply to G-codes. | N | N | 1 | N/A |
| CAHPS for MIPs Clinician/Group Survey | 321 | |||||||
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | 322 | Procedure | N/A | Y | N | 1 | N/A | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | 323 | Procedure | N/A | Y | N | 1 | N/A | |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | 324 | Procedure | N/A | Y | N | 1 | N/A | |
| Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | 325 | Patient - Process | N/A | N | N | 1 | N/A | |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Pediatric Kidney Disease: Adequacy of Volume Management | 327 | Patient - Periodic | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL | 328 | Patient - Periodic | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | 329 | Patient - Process | N/A | No requirement exists to report both measures (329 and 330) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | 330 | Patient - Process | N/A | No requirement exists to report both measures (329 and 330) when paired. Any paired measure reported would count as an individual measure. The system should not require that an eligible clinician report both of the paired measures. The system should consider each of these measures as an individually reportable measure. An eligible clinician may report both or only one of the paired measures as part of the measures threshold required for data completeness. For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | 333 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | 334 | Visit | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse) | 335 | Procedure | N/A | N | N | 1 | N/A | |
| Maternity Care: Post-Partum Follow-Up and Care Coordination | 336 | Patient - Process | N/A | N | N | 1 | N/A | |
| Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier | 337 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| HIV Viral Load Suppression | 338 | Patient - Process | N/A | N | N | 1 | N/A | |
| HIV Medical Visit Frequency | 340 | Patient - Process | N/A | N | N | 1 | N/A | |
| Pain Brought Under Control Within 48 Hours | 342 | Patient - Process | N/A | N | N | 1 | N/A | |
| Screening Colonoscopy Adenoma Detection Rate | 343 | Procedure | N/A | CPT codes 45378, 45380, 45381, 45384, 45385, 45380 that has a modifier 52, 53, 73 or 74 are not to be included in the eligible denominator. Modifiers not relevant for G0121, because CPT I modifiers do not apply to G-codes. | N | N | 1 | N/A |
| Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | 344 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive | 345 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive | 346 | Procedure | N/A | N | N | 1 | N/A | |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive | 347 | Procedure | N/A | N | N | 1 | N/A | |
| HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | 348 | Patient - Process | N/A | An overall data completeness and performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall data completeness is determined by summing the data completeness numerator counts of each submeasure and dividing by the sum of the data completeness denominator counts of each submeasure. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. There are 2 performance rates to be calculated for this measure: 1. Complications or mortality at 30 days OR 2. Complications at 90 days | Y | N | 2 | Weighted Average |
| Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | 350 | Procedure | N/A | N | N | 1 | N/A | |
| Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | 351 | Procedure | N/A | N | N | 1 | N/A | |
| Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | 352 | Procedure | N/A | N | N | 1 | N/A | |
| Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | 353 | Procedure | N/A | N | N | 1 | N/A | |
| Anastomotic Leak Intervention | 354 | Procedure | N/A | Y | N | 1 | N/A | |
| Unplanned Reoperation within the 30 Day Postoperative Period | 355 | Procedure | N/A | Y | N | 1 | N/A | |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | 356 | Procedure | N/A | Y | N | 1 | N/A | |
| Surgical Site Infection (SSI) | 357 | Procedure | N/A | Y | N | 1 | N/A | |
| Patient-Centered Surgical Risk Assessment and Communication | 358 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | 359 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | 360 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | 361 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison | 362 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive | 363 | Procedure | N/A | N | N | 1 | N/A | |
| Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 364 | Procedure | N/A | N | N | 1 | N/A | |
| Follow-Up Care for Children Prescribed ADHD Medication (ADD) | 366 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of two performance rates (Intake & Continuation and Maintenance Phase). An overall performance rate needs to be calculated for this measure. A simple average of the performance rates will be determined to calculate the overall performance rate. This is determined by adding the performance rate percentages for each submeasure and divide by the total number of component submeasures. | N | N | 2 | Simple Average |
| Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use | 367 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Depression Remission at Twelve Months | 370 | Patient - Process | Patient-Based Measure | NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and a PHQ-9 Score greater than 9 documented on the same date (index event) and this date occurs during denominator identification period (11/1/2016 to 10/31/2017). Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis. | N | N | 1 | N/A |
| Depression Utilization of the PHQ-9 Tool | 371 | N/A | Patient-Based Measure | The eCQM measure requires the reporting of three performance rates. An overall performance rate needs to be calculated for this measure. A weighted average will be determined at the numerator and denominator count level. The overall performance rate is determined by summing the performance numerator counts of each submeasure and dividing by the sum of the performance denominator counts of each submeasure. | N | N | 3 | Weighted Average |
| Maternal Depression Screening | 372 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Hypertension: Improvement in Blood Pressure | 373 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | Patient - Process | Patient-Based Measure | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Functional Status Assessment for Total Knee Replacement | 375 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Functional Status Assessment for Total Hip Replacement | 376 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Functional Status Assessments for Congestive Heart Failure | 377 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Children Who Have Dental Decay or Cavities | 378 | N/A | Patient-Based Measure | Y | N | 1 | N/A | |
| Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 379 | N/A | Patient-Based Measure | N | N | 1 | N/A | |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | N/A | Episode-of-Care Measure | N | N | 1 | N/A | |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | Patient - Process | N/A | N | Y | 1 | N/A | |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | Procedure | N/A | N | N | 1 | N/A | |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | Procedure | N/A | N | N | 1 | N/A | |
| Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | 386 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | 387 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) | 388 | Procedure | N/A | Y | N | 1 | N/A | |
| Cataract Surgery: Difference Between Planned and Final Refraction | 389 | Procedure | N/A | N | N | 1 | N/A | |
Needed Columns 3
| Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | 390 | Patient - Process | N/A | N | N | 1 | N/A | |
| Follow-Up After Hospitalization for Mental Illness (FUH) | 391 | Visit | N/A | The measure has multiple denominator options. Acute inpatient setting discharges between January 1st and December 1st of the measurement period is one of the denominator criteria. This measure requires the reporting of two performance rates. The second performance rate (Percentage of discharges for which patient received follow-up within 7 days of discharge) defined in the measure will be utilized as the overall data completeness and performance rate for this measure. This measure requires the reporting of two performance rates. (1) Percentage of discharges for which the patient received follow-up within 30 days of discharge. (2) Percentage of discharges for which the patient received follow-up within 7 days of discharge. | N | N | 2 | 2nd Performance Rate |
| HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | 392 | Patient - Process | N/A | This measure has multiple denominator options. This measure requires the reporting of five performance rates but only one data completeness is required. The fifth performance rate outlined below should be utilized for an overall data completeness and performance rate for this measure. This measure requires the reporting of five performance rates. 1) Females less than 65 years of age 2) Males less than 65 years of age 3) Females 65 years of age and older 4) Males 65 years of age and older 5) Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days | Y | N | 5 | 5th Performance Rate |
| HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | 393 | Patient - Process | N/A | This measure requires the reporting of only one data completeness and performance rate. There are two reporting criteria for this measure: 1) Patients, regardless of age, with a new CIED OR 2) Patients, regardless of age, with a replaced or revised CIED | Y | N | 1 | N/A |
| Immunizations for Adolescents | 394 | Patient - Process | N/A | This measure requires the reporting of four performance rates. The third performance rate outlined below should be utilized for an overall data completeness and performance rate for this measure. This measure will be calculated with 4 performance rates: 1) Patients who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays 2) Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the patient’s 10th and 13th birthdays 3) Patients who had at least three HPV vaccines with different dates of service on or between the patient's 9th and 13th birthdays 4) All patients who are compliant for both Meningococcal AND Td/Tdap AND HPV during the specified timeframes. | N | N | 4 | 4th Performance Rate |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Lung Cancer Reporting (Resection Specimens) | 396 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Melanoma Reporting | 397 | Procedure | N/A | Claims: Only one QDC per date of service for a patient is required. | N | N | 1 | N/A |
| Optimal Asthma Control | 398 | Patient - Process | N/A | The measure has multiple denominator options. This measure requires the reporting of seven performance rates. The first performance rate outlined below should be utilized for an overall data completeness and performance rate for this measure. This measure should be calculated with 7 performance rates: 1. Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation. 2. Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation. 3. Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation. 4. Asthma well-controlled (take the most recent ACT) for patients 5 to 17 with Asthma 5. Asthma well-controlled (take the most recent ACT) for patients 18 to 50 with Asthma 6. Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma 7. Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma | N | N | 7 | 1st Performance Rate |
| One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | 400 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | Patient - Process | N/A | N | N | 1 | N/A | |
| Tobacco Use and Help with Quitting Among Adolescents | 402 | Patient - Process | N/A | N | N | 1 | N/A | |
| Adult Kidney Disease: Referral to Hospice | 403 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Anesthesiology Smoking Abstinence | 404 | Procedure (Regardless of TIN/NPI) | N/A | N | N | 1 | N/A | |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Procedure | N/A | Y | N | 1 | N/A | |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Procedure | N/A | Y | N | 1 | N/A | |
| Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | 407 | Episode (Regardless of TIN/NPI) | N/A | Claims: Utilize Part B Claims. Correlate eligible cases with inpatient "hidden" codes at the bene-level regardless of TIN/NPI to determine the length of hospital stay (episode). "Hidden" inpatient code line items that are denied or include modifier 80, 81 or 82 should be included in this analysis. •REFER TO THE "HIDDEN CODES" TAB OF THE SINGLE SOURCE FOR A COMPLETE LISTING OF CPT I INPATIENT "HIDDEN" CODES • Inpatient "hidden" CPT I codes are counted once per hospital stay • Multiple ICD10 codes on the same claim are counted once • Maximum one episode per claim (even if there is a break in DOS for inpatient "hidden" CPT I codes on that claim) • Count any inpatient "hidden" CPT I in a string of consecutive DOS at bene level for all TIN/NPI as one episode • Look across claims to determine the episode based on "consecutive dates of service," use the earliest DOS for an inpatient "hidden" CPT I code and the latest DOS for an inpatient "hidden" CPT I code on each claim to identify claims with consecutive DOS. • Most favorable instance of reporting is used in performance rate | N | N | 1 | N/A |
| Opioid Therapy Follow-up Evaluation | 408 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Clinical Outcome Post Endovascular Stroke Treatment | 409 | Procedure | N/A | NOTE: Include only patients that have cerebrovascular accidents through September 30 of the performance period. This will allow the evaluation of at least 90 days after the cerebrovascular accident within the performance period. | N | N | 1 | N/A |
| Psoriasis: Clinical Response to Systemic Medications | 410 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Depression Remission at Six Months | 411 | Patient - Process | N/A | NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and a PHQ-9 Score greater than 9 documented on the same date (index event) and this date occurs during the denominator identification measurement period (11/1/2016 to 10/31/2017). Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis. | N | N | 1 | N/A |
| Documentation of Signed Opioid Treatment Agreement | 412 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Door to Puncture Time for Endovascular Stroke Treatment | 413 | Procedure | N/A | N | N | 1 | N/A | |
| Evaluation or Interview for Risk of Opioid Misuse | 414 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | Visit | N/A | Claims: The patient should have CPT 70450 (regardless of TIN/NPI) on the same date of service as the denominator eligible encounter in order to be included in the denominator. | N | N | 1 | N/A |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Visit | N/A | Claims: The patient should have CPT 70450 (regardless of TIN/NPI) on the same date of service as the denominator eligible encounter in order to be included in the denominator. | Y | N | 1 | N/A |
| Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive | 417 | Procedure | N/A | N | N | 1 | N/A | |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Episode (TIN/NPI/Bene-level) | N/A | Claims: Count each unique diagnosis as an episode for an TIN/NPI/Bene unless multiple diagnoses appear on the same claim. • Multiple qualifying ICD10 or CPT I procedures on a single claim are counted once. (A single claim can be counted a maximum of once for an episode per TIN/NPI/Bene combo regardless of the number of qualifying DXs or procedures that exist.) • Multiple claims with any intersecting diagnosis will be counted once. Intersecting claims with diagnosis codes will be counted once. All claims that share diagnosis codes are combined into one episode, given they have the same TIN/NPI/Bene • If the TIN/NPI/Bene combo has multiple claims containing *different* qualifying DX codes that have not been submitted during the performance period, then these claims may each count as additional episodes. • Use the most favorable instance of reporting for performance rates if multiple conflicting QDCs exist on a qualifying episode. • The QDC must exist on the claim with the qualifying denom episode (overarching rule for all measures). | N | N | 1 | N/A |
| Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination | 419 | Visit | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | 420 | Procedure | N/A | N | N | 1 | N/A | |
| Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | 421 | Procedure | N/A | N | N | 1 | N/A | |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Procedure | N/A | N | N | 1 | N/A | |
| Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy | 423 | Procedure | N/A | N | N | 1 | N/A | |
| Perioperative Temperature Management | 424 | Procedure | N/A | N | N | 1 | N/A | |
| Photodocumentation of Cecal Intubation | 425 | Procedure | N/A | Denominator eligible CPT codes submitted with a modifier 73 and 74 should be excluded from the denominator for claims or excluded by the registry. If QDCs are submitted on the same claim for multiple measures, exclude only the line item with the modifier. | N | N | 1 | N/A |
| Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) | 426 | Procedure | N/A | N | N | 1 | N/A | |
| Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) | 427 | Procedure | N/A | N | N | 1 | N/A | |
| Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | 428 | Procedure | N/A | N | N | 1 | N/A | |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Procedure | N/A | N | N | 1 | N/A | |
| Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | 430 | Procedure | N/A | N | N | 1 | N/A | |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | Patient - Process | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | 432 | Procedure | N/A | Y | N | 1 | N/A | |
| Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 433 | Procedure | N/A | Y | N | 1 | N/A | |
| Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair | 434 | Procedure | N/A | Y | N | 1 | N/A | |
| Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Patient - Intermediate | N/A | Claims: Two denominator eligible visits for the same TIN/NPI with two different dates of service are required to be denominator eligible. The QDC needs to be reported on the 2nd visit (based on date of service) or a subsequent visit if more than two visits are found within the reporting period. A QDC submitted on the first visit (based on date of service) in the reporting period will not be counted. The most advantageous QDC should be utilized if multiple QDCs are submitted on any visit but the first visit within the reporting period. For the numerator, quality of life assessments with MIDAS must be separated by at least 90 days (4 weeks for any other tool). For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Procedure | N/A | N | Y | 1 | N/A | |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Procedure | N/A | Include only patients undergoing an endovascular lower extremity revascularization procedure through December 29 of the reporting period. This will allow the evaluation of at least 48 hours of the procedure within the reporting year. | Y | N | 1 | N/A |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | Patient - Process | N/A | The measure has multiple reporting criteria. This measure requires the reporting of only one reporting and performance rate. All considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: 1. Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR 2. Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR 3. Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | Y | 1 | N/A |
| Age Appropriate Screening Colonoscopy | 439 | Procedure | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | Y | N | 1 | N/A |
| Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician | 440 | Procedure | N/A | N | N | 1 | N/A | |
| Persistence of Beta-Blocker Treatment After a Heart Attack | 442 | Patient - Process | N/A | N | N | 1 | N/A | |
| Non-Recommended Cervical Cancer Screening in Adolescent Females | 443 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Medication Management for People with Asthma | 444 | Patient - Process | N/A | N | Y | 1 | N/A | |
| Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | 445 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Operative Mortality Stratified by the Five STS-EACTS Mortality Categories | 446 | Procedure | N/A | There are two reporting criteria for this measure and one performance rate. | Y | N | 1 | N/A |
| Chlamydia Screening and Follow Up | 447 | Patient - Process | N/A | N | Y | 1 | N/A | |
| Appropriate Work Up Prior to Endometrial Ablation | 448 | Procedure | N/A | N | Y | 1 | N/A | |
| HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies | 449 | Patient - Intermediate | N/A | N | N | 1 | N/A | |
| Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy | 450 | Patient - Intermediate | N/A | N | N | 1 | N/A | |
| RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | 451 | Patient - Process | N/A | N | N | 1 | N/A | |
| Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | 452 | Patient - Process | N/A | N | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better) | 453 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life (lower score - better) | 454 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better) | 455 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Not Admitted To Hospice (lower score - better) | 456 | Patient - Process | N/A | Y | N | 1 | N/A | |
| Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better) | 457 | Patient - Process | Y | N | 1 | N/A | ||
| All-cause Hospital Readmission | 458 | |||||||
| Average Change in Back Pain following Lumbar Discectomy / Laminotomy | 459 | Visit | N/A | N | Y | 2 | 1st Performance Rate | |
| Average Change in Back Pain following Lumbar Fusion | 460 | Visit | N/A | N | Y | 2 | 1st Performance Rate | |
| Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy | 461 | Visit | N/A | N | Y | 2 | 1st Performance Rate | |
| Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | 462 | N/A | N/A | N | N | 1 | N/A | |
| Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | 463 | Procedure | N/A | N | Y | 1 | N/A | |
| Otitis Media with Effusion: Systemic Antimicrobials- Avoidance of Inappropriate Use | 464 | Episode | N/A | For denominator criteria, encounter codes with Telehealth modifiers GQ, GT, 95 and POS 02 would not be considered encounter (eligible cases). | N | N | 1 | N/A |
| Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | 465 | Procedure | N/A | N | N | 1 | N/A | |
| Developmental Screening in the First Three Years of Life | 467 | Visit | N/A | The intent of this measure is to calculate a Total Performance Rate based on all children who turned 1, 2, or 3 during the performance period who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday, i.e., the sum of denominators 1, 2, and 3. There are three submission criteria for this measure and a total performance rate that is the sum of the three submission criteria.1) Children in the eligible population who turned 1 during the performance period. (Birth to 1 year of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday OR 2) Children in the eligible population who turned 2 during the performance period (> 1 year to 2 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday OR 3) Children in the eligible population who turned 3 during the performance period ( > 2 years to 3 years of age) who were screened for risk of developmental, behavioral and social delays using a standardized tool with interpretation and report within 12 months preceding or on their birthday 4. The total performance rate is calcuated calculated as the sum of Performance for criteria 1, 2 and 3. | N | N | 4 | 4th total performance rate |
| Continuity of Pharmacotherapy for Opioid Use Disorder | MUC17-139 (Quality) | |||||||
| Average change in functional status following lumbar spine fusion surgery | MUC17-168 (Quality) | |||||||
| Average change in functional status following total knee replacement surgery | MUC17-169 (Quality) | |||||||
| Average change in functional status following lumbar discectomy laminotomy surgery | MUC17-170 (Quality) | |||||||
| Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | MUC17-173 (Quality) | |||||||
| Average change in leg pain following lumbar spine fusion surgery | MUC17-177 (Quality) | |||||||
| Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication | MUC17-234 (Quality) | |||||||
| Zoster (Shingles) Vaccination | MUC17-310 (Quality) | |||||||
| HIV Screening | MUC17-367 (Quality) | |||||||
| Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls |
Measure Steward Contacts
| Appendix I - Measure Steward/Contact Information | ||
| Full Name | Contact | Other Contacts |
| Agency for Healthcare Research & Quality | email questions and comments to [email protected] | |
| American Academy of Allergy, Asthma, and Immunology | email questions and comments to [email protected] | |
| American Academy of Dermatology | email questions and comments to [email protected] | |
| American Academy of Neurology | email questions and comments to [email protected] & [email protected] | |
| American Academy of Ophthalmology | email questions and comments to [email protected] | [email protected], [email protected], [email protected] |
| American Academy of Orthopedic Surgeons | email questions and comments to [email protected] | |
| American Academy of Otolaryngology - Head and Neck Surgery | email questions and comments to [email protected] | |
| American Academy of Sleep Medicine | email questions and comments to [email protected] | |
| American Association of Hip and Knee Surgeons | American Association of Hip and Knee Surgeons | |
| American College of Cardiology | email questions and comments to [email protected] | [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected] |
| American College of Cardiology Foundation | email questions and comments to [email protected] | same as above |
| American College of Emergency Physicians | email questions and comments to [email protected] | [email protected], [email protected], [email protected], [email protected] |
| American College of Gastroenterology | email questions and comments to [email protected] | |
| American College of Radiology | email questions and comments to [email protected] | |
| American College of Rheumatology | email questions and comments to [email protected] | |
| American College of Surgeons | email questions and comments to [email protected] | |
| American Gastroenterological Association | email questions and comments to [email protected] | |
| American Heart Association | email questions and comments to [email protected] | |
| American Medical Association - Physician Consortium for Performance Improvement | email questions and comments to the PCPI at [email protected] | |
| American Podiatric Medical Association | email questions and comments to [email protected] | |
| American Psychiatric Association | Visit Psychiatry.org and select "Contact" | |
| American Psychological Association | email questions and comments to [email protected] | |
| American Society for Radiation Oncology | email questions and comments to [email protected] & [email protected] | |
| American Society of Anesthesiologists | email questions and comments to [email protected] | |
| American Society of Breast Surgeons | email questions and comments to [email protected] | |
| American Society of Clinical Oncology | email questions and comments to [email protected] & [email protected] | |
| American Society of Plastic Surgeons | email questions and comments to [email protected] | |
| American Thoracic Society | email questions and comments to [email protected] | |
| American Urogynecologic Society | email questions and comments to [email protected] | |
| Audiology Quality Consortium | email questions and comments to [email protected], or [email protected] | |
| Center for Quality Assessment and Improvement in Mental Health | Visit Center for Quality Assessment and select "Contact Us" | |
| Centers for Medicare & Medicaid Services | email questions and comments to [email protected] | |
| College of American Pathologists | email questions and comments to [email protected] | |
| Focus on Therapeutic Outcomes, Inc. | email questions and comments to [email protected] | |
| Health Resources and Services Administration | email questions and comments to [email protected] | |
| Infectious Diseases Society of America | Visit the Infectious Diseases Society of America | |
| Minnesota Community Measurement | email questions and comments to [email protected] | |
| National Committee for Quality Assurance | Visit NCQA and select "Contact Us." | |
| National Hospice and Palliative Care Organization | email questions and comments to [email protected] | |
| Oregon Health and Science University (OPIP) | email questions and comments to [email protected] | |
| Oregon Urology Institute | email questions and comments to [email protected] | |
| Renal Physicians Association | email questions and comments to [email protected] | |
| Society for Vascular Surgeons | Visit vascularweb.org and select "Contact Us" | |
| Society of Interventional Radiology | email questions and comments to [email protected] | |
| Society of Thoracic Surgeons | email questions and comments to [email protected] | |
| The Heart Rhythm Society | email questions and comments to [email protected] | |
| Wisconsin Collaborative for Healthcare Quality | email questions and comments to [email protected] |
Version History
| Version History (changes from v3.0 to v3.1) |
| Updated eCQM NQF IDs for MIPS #005, #008, #370, #371 and #382 |
| Updated NQF ID column for MIPS #111, #370, #371, #382 and #448 |
| Renamed "Meaningful Measurement Area" to "Meaningful Measure Area" to reflect current terminology |
| Removed "X" for Medicare Part B Claims for MIPS #410 as this measure is not available for reporting as a claims-based measure in 2019 |
| Removed the "General Oncology" Specialty Set column as there are no measures identified for this specialty set or in the column for 2019 |
| Updated email address links on the Measure Steward Contact list, as needed (i.e. American Academy of Dermatology, American Academy of Neurology, American College of Rheumatology, American College of Surgeons, American Society for Radiation Oncology, American Society of Clinical Oncology, Audiology Quality Consortium) |
| Version History (changes from v3.1 to v3.2) |
| Updated High Priority status for MIPS #305 |
| Updated Appropriate Use for MIPS #464 |
| Updated "Patient Reported Functional Outcomes" Meaningful Measure Area for MIPS #182, #217, #218, #219, #220, #221, #222, #223, #303, #304, #321, #375, #376, #377, #385, #389, #420, #435, #459, #460, #461, #469, #470, #471, and #473 to "Functional Outcomes" per new subregulatory guidance |
Process Notes
| Process Notes |
| To verify meaningful measures/priority, I used synkronizer to compare 2019 to 2018 measures |
| To verify meaningful measures/priority, I used synkronizer to compare 2019 to 2018 measures |
| Ensure all MUC measures from 2019 proposed rule that are included and excluded are respectively included and excluded in warehouse |
| For MUCs: x indicates that meaningful measure, priority, and date have been checked |
| Year added is default 2017: MUCs have been modified |
| MUCS begin on Proposed Rule on PDF pg 1197 |
| 2019 Proposed rules reviewe: MUCs added and removed accordingly |
Measure Title
Measure Title
CMS eCQM
ID
eCQM
NQF
NQF
Quality
Number
(Q#)
Parkinson’s Disease: Psychiatric Symptoms
Assessment for Patients with Parkinson’s Disease
N/AN/AN/A290
Parkinson’s Disease: Cognitive Impairment or
Dysfunction Assessment for Patients with
Parkinson's Disease
N/AN/AN/A291
Measure Number
CMS eCQM
ID
eCQM
NQF
NQF
Quality
Number
(Q#)
Measure Number
Measure Title
CMS eCQM
ID
eCQM
NQF
NQF
Quality
Number
(Q#)
Documentation of Current Medications in the
Medical Record
CMS68v8N/A0419130
Measure Number
NQS Domain
Measure Title
CMS eCQM
ID
eCQM
NQF
NQF
Quality
Number
(Q#)
Measure DescriptionNQS Domain
Diabetes: Hemoglobin A1c (HbA1c) Poor Control
(>9%)
CMS122v7N/A0059001
Percentage of patients 18-75 years of age with diabetes who had
hemoglobin A1c > 9.0% during the measurement period
Effective Clinical Care
Heart Failure (HF): Angiotensin-Converting
Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left Ventricular
Systolic Dysfunction (LVSD)
CMS135v72907
0081
005
Percentage of patients aged 18 years and older with a diagnosis
of heart failure (HF) with a current or prior left ventricular
ejection fraction (LVEF) < 40% who were prescribed ACE
inhibitor or ARB therapy either within a 12-month period when
seen in the outpatient setting OR at each hospital discharge
Effective Clinical Care
Coronary Artery Disease (CAD): Antiplatelet
Therapy
N/AN/A0067006
Percentage of patients aged 18 years and older with a diagnosis
of coronary artery disease (CAD) seen within a 12 month
period who were prescribed aspirin or clopidogrel
Effective Clinical Care
Measure Number
Medicare
Part B
Claims
CSVeCQM
CMS
Web
Interface
Administrative
Claims
MIPS
CQM
Collection Type(s)
Medicare
Part B
Claims
CSVeCQM
CMS
Web
Interface
Administrative
Claims
MIPS
CQM
X-XX-X
--X--X
-----X
Collection Type(s)
