Final project 3-4

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2019MIPSQualityBenchmarks.xlsx
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Column Descriptions

Table 1: Column Descriptions for the MIPS Benchmark Results worksheet
Physical Column Name Description
Measure_Name Name\Title of the Measure
Measure_ID ID of the Measure
Collection_Type Identifies whether the benchmark applies to Medicare Part B Claims measures, electronic clinical quality measures (eCQMs), MIPS clinical quality measures (MIPS CQMs), or QCDR measures. CMS Web Interface measures use Shared Savings Program benchmarks. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2019-quality-benchmarks-guidance.pdf.
Measure_Type Measure Type
Benchmark Indicates whether or not a measure is included in the benchmark analysis. Y = Yes, the measure is included in benchmark analysis N = No, the measure is not included in benchmark analysis
Standard Deviation Standard Deviation of performance rate(s)
Average Average performance rate(s)
Decile 3 The lower and upper bound of decile 3 data range
Decile 4 The lower and upper bound of decile 4 data range
Decile 5 The lower and upper bound of decile 5 data range
Decile 6 The lower and upper bound of decile 6 data range
Decile 7 The lower and upper bound of decile 7 data range
Decile 8 The lower and upper bound of decile 8 data range
Decile 9 The lower and upper bound of decile 9 data range
Decile 10 Decile 10 open ended data range
Topped_Out Indicates whether or not a measure is topped out for the 2019 performance period. Y = Yes, the measure is topped out N = No, the measure is not topped out '--' = The measure has no historic benchmark for 2019
SevenPointCap_PY19 Indicates whether or not a Topped Out Measure will receive special scoring. Y=Yes, the measure cannot earn more than 7 points. N=No, the measure is not capped and can earn up to 10 points.

MIPS Benchmark Results

Table 2: Historical MIPS Quality Measure Benchmark Results; created using PY2017 data and PY2019 Eligibility Rules
Measure_Name Measure_ID Collection_Type Measure_Type Benchmark Standard_Deviation Average Decile_3 Decile_4 Decile_5 Decile_6 Decile_7 Decile_8 Decile_9 Decile_10 TOPPED_OUT SevenPointCap
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 1 eCQM Intermediate Outcome Y 28.2 46.3 77.14 - 60.79 60.78 - 48.49 48.48 - 38.90 38.89 - 31.60 31.59 - 25.88 25.87 - 20.56 20.55 - 14.72 <= 14.71 No No
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 1 Medicare Part B Claims Intermediate Outcome Y 24.5 24.6 44.44 - 29.04 29.03 - 19.52 19.51 - 14.72 14.71 - 11.12 11.11 - 8.34 8.33 - 5.57 5.56 - 2.79 <= 2.78 No No
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 1 MIPS CQM Intermediate Outcome Y 30.1 36.5 68.31 - 50.63 50.62 - 37.51 37.50 - 28.70 28.69 - 20.01 20.00 - 13.60 13.59 - 9.03 9.02 - 2.71 <= 2.70 No No
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5 eCQM Process Y 13.8 82.8 74.19 - 78.56 78.57 - 82.13 82.14 - 85.18 85.19 - 87.92 87.93 - 90.90 90.91 - 93.74 93.75 - 97.72 >= 97.73 No No
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5 MIPS CQM Process Y 13.5 94.1 93.33 - 96.96 96.97 - 98.40 98.41 - 99.99 -- -- -- -- 100 Yes No
Coronary Artery Disease (CAD): Antiplatelet Therapy 6 MIPS CQM Process Y 13.2 89.6 84.13 - 87.99 88.00 - 90.66 90.67 - 92.85 92.86 - 95.09 95.10 - 97.08 97.09 - 99.99 -- 100 No No
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) 7 eCQM Process Y 13.7 82.9 76.74 - 80.30 80.31 - 83.17 83.18 - 85.28 85.29 - 87.15 87.16 - 89.73 89.74 - 91.91 91.92 - 94.86 >= 94.87 No No
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) 7 MIPS CQM Process Y 8.8 96.3 96.17 - 98.11 98.12 - 99.76 99.77 - 99.99 -- -- -- -- 100 Yes No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 8 eCQM Process Y 11.1 87.9 80.49 - 85.61 85.62 - 88.97 88.98 - 91.29 91.30 - 93.04 93.05 - 94.73 94.74 - 96.34 96.35 - 99.99 100 No No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 8 MIPS CQM Process Y 10.3 95.9 95.45 - 98.05 98.06 - 99.28 99.29 - 99.99 -- -- -- -- 100 Yes No
Anti-Depressant Medication Management 9 eCQM Process Y 32.4 53.9 16.67 - 31.06 31.07 - 42.18 42.19 - 53.15 53.16 - 71.73 71.74 - 82.78 82.79 - 88.88 88.89 - 94.43 >= 94.44 No No
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 12 eCQM Process Y 20 86.2 79.11 - 86.57 86.58 - 90.61 90.62 - 93.87 93.88 - 96.31 96.32 - 98.01 98.02 - 99.10 99.11 - 99.99 100 No No
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 12 Medicare Part B Claims Process Y 9.8 97.4 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 12 MIPS CQM Process Y 9.8 96.2 96.47 - 99.16 99.17 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Age-Related Macular Degeneration (AMD): Dilated Macular Examination 14 Medicare Part B Claims Process Y 10.2 97.8 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Age-Related Macular Degeneration (AMD): Dilated Macular Examination 14 MIPS CQM Process Y 24.3 86.2 76.54 - 89.80 89.81 - 96.53 96.54 - 99.70 99.71 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 19 eCQM Process Y 28.8 61.7 33.90 - 47.61 47.62 - 57.88 57.89 - 67.02 67.03 - 75.36 75.37 - 82.48 82.49 - 90.02 90.03 - 95.99 >= 96.00 No No
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 19 Medicare Part B Claims Process Y 8.6 98.2 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 19 MIPS CQM Process Y 26.6 83.4 70.29 - 84.41 84.42 - 92.72 92.73 - 98.56 98.57 - 99.99 -- -- -- 100 Yes No
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin 21 Medicare Part B Claims Process Y 22.6 92 99.17 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin 21 MIPS CQM Process Y 17.5 94.6 98.67 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) 23 Medicare Part B Claims Process Y 19.9 94.9 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) 23 MIPS CQM Process Y 17.4 95 98.68 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older 24 Medicare Part B Claims Process Y 31.9 76.3 32.35 - 63.63 63.64 - 92.30 92.31 - 96.20 96.21 - 97.61 97.62 - 99.99 -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older 24 MIPS CQM Process Y 32.4 59.6 26.32 - 45.09 45.10 - 55.31 55.32 - 60.20 60.21 - 69.99 70.00 - 80.55 80.56 - 99.99 -- 100 No No
Screening for Osteoporosis for Women Aged 65-85 Years of Age 39 Medicare Part B Claims Process Y 26.5 56.2 32.79 - 42.36 42.37 - 49.00 49.01 - 55.90 55.91 - 62.54 62.55 - 70.68 70.69 - 82.88 82.89 - 95.49 >= 95.50 No No
Screening for Osteoporosis for Women Aged 65-85 Years of Age 39 MIPS CQM Process Y 31 46.2 11.38 - 22.43 22.44 - 34.71 34.72 - 45.25 45.26 - 58.10 58.11 - 67.97 67.98 - 78.45 78.46 - 88.23 >= 88.24 No No
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery 44 MIPS CQM Process Y 14.7 92.7 90.35 - 95.89 95.90 - 97.38 97.39 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Medication Reconciliation Post-Discharge 46 Medicare Part B Claims Process Y 16.3 94.2 95.74 - 98.40 98.41 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Medication Reconciliation Post-Discharge 46 MIPS CQM Process Y 17.2 93.3 94.24 - 97.62 97.63 - 99.92 99.93 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Care Plan 47 Medicare Part B Claims Process Y 33.1 78.4 50.32 - 82.60 82.61 - 92.88 92.89 - 97.45 97.46 - 99.30 99.31 - 99.99 -- -- 100 Yes No
Care Plan 47 MIPS CQM Process Y 35.9 66.1 24.33 - 45.01 45.02 - 65.74 65.75 - 82.16 82.17 - 91.89 91.90 - 97.31 97.32 - 99.71 99.72 - 99.99 100 No No
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 48 Medicare Part B Claims Process Y 43.1 65 3.88 - 13.85 13.86 - 72.40 72.41 - 96.68 96.69 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 48 MIPS CQM Process Y 37.5 59.8 12.22 - 31.74 31.75 - 52.36 52.37 - 70.44 70.45 - 84.26 84.27 - 95.10 95.11 - 99.50 99.51 - 99.99 100 No No
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older 50 Medicare Part B Claims Process Y 18.2 94.4 97.30 - 98.87 98.88 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older 50 MIPS CQM Process Y 26.6 71.4 47.22 - 59.99 60.00 - 68.98 68.99 - 75.63 75.64 - 85.49 85.50 - 92.58 92.59 - 99.65 99.66 - 99.99 100 No No
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 51 Medicare Part B Claims Process Y 33.7 77 38.10 - 77.26 77.27 - 92.44 92.45 - 98.75 98.76 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 51 MIPS CQM Process Y 33.4 64.9 25.00 - 45.44 45.45 - 60.42 60.43 - 75.75 75.76 - 86.45 86.46 - 93.82 93.83 - 99.35 99.36 - 99.99 100 No No
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy 52 Medicare Part B Claims Process Y 21.9 89.9 90.14 - 98.14 98.15 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy 52 MIPS CQM Process Y 13.4 93.1 90.16 - 95.21 95.22 - 96.48 96.49 - 98.85 98.86 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Appropriate Treatment for Children with Upper Respiratory Infection (URI) 65 eCQM Process Y 15.8 88.1 80.95 - 88.36 88.37 - 91.76 91.77 - 93.87 93.88 - 95.60 95.61 - 96.87 96.88 - 98.21 98.22 - 99.99 100 No No
Appropriate Treatment for Children with Upper Respiratory Infection (URI) 65 MIPS CQM Process Y 13.9 93.2 91.49 - 95.01 95.02 - 97.02 97.03 - 97.84 97.85 - 98.69 98.70 - 99.19 99.20 - 99.74 99.75 - 99.99 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Appropriate Testing for Children with Pharyngitis 66 eCQM Process Y 29.6 66.7 36.71 - 60.04 60.05 - 72.40 72.41 - 78.37 78.38 - 83.32 83.33 - 87.62 87.63 - 91.42 91.43 - 94.58 >= 94.59 No No
Appropriate Testing for Children with Pharyngitis 66 MIPS CQM Process Y 17.5 77.4 64.57 - 69.60 69.61 - 75.41 75.42 - 81.74 81.75 - 85.50 85.51 - 87.95 87.96 - 91.77 91.78 - 97.54 >= 97.55 No No
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow 67 MIPS CQM Process Y 38.1 42.9 8.00 - 12.49 12.50 - 22.72 22.73 - 28.52 28.53 - 34.61 34.62 - 78.78 78.79 - 99.99 -- 100 No No
Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy 68 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Hematology: Multiple Myeloma: Treatment with Bisphosphonates 69 MIPS CQM Process Y 21.1 61.5 42.86 - 47.49 47.50 - 64.51 64.52 - 66.66 66.67 - 71.42 71.43 - 71.87 71.88 - 76.91 76.92 - 92.30 >= 92.31 No No
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry 70 MIPS CQM Process Y 36.5 53.1 16.67 - 23.20 23.21 - 32.25 32.26 - 35.94 35.95 - 67.85 67.86 - 95.44 95.45 - 99.99 -- 100 No No
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections 76 Medicare Part B Claims Process Y 17.3 93.7 95.24 - 98.60 98.61 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections 76 MIPS CQM Process Y 15.7 94.2 95.67 - 99.08 99.09 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Acute Otitis Externa (AOE): Topical Therapy 91 Medicare Part B Claims Process Y 32.6 78.5 43.36 - 86.60 86.61 - 93.21 93.22 - 99.65 99.66 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Acute Otitis Externa (AOE): Topical Therapy 91 MIPS CQM Process Y 20 83.2 67.34 - 78.76 78.77 - 86.33 86.34 - 91.32 91.33 - 95.23 95.24 - 97.36 97.37 - 99.99 -- 100 No No
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use 93 Medicare Part B Claims Process Y 21.6 88.7 89.12 - 93.50 93.51 - 96.35 96.36 - 97.82 97.83 - 99.92 99.93 - 99.99 -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use 93 MIPS CQM Process Y 23.7 80.1 63.16 - 77.35 77.36 - 83.96 83.97 - 89.65 89.66 - 93.32 93.33 - 96.14 96.15 - 99.99 -- 100 No No
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 102 eCQM Process Y 29.8 78.3 59.34 - 75.73 75.74 - 83.90 83.91 - 91.99 92.00 - 98.30 98.31 - 99.99 -- -- 100 No No
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 102 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer 104 MIPS CQM Process Y 30.6 69 39.65 - 48.16 48.17 - 55.05 55.06 - 76.22 76.23 - 93.25 93.26 - 99.59 99.60 - 99.99 -- 100 No No
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 107 eCQM Process Y 36 33.9 1.51 - 3.56 3.57 - 8.10 8.11 - 17.48 17.49 - 30.28 30.29 - 54.72 54.73 - 77.56 77.57 - 96.66 >= 96.67 No No
Osteoarthritis (OA): Function and Pain Assessment 109 Medicare Part B Claims Process Y 22.9 89.2 87.28 - 95.71 95.72 - 98.71 98.72 - 99.88 99.89 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Osteoarthritis (OA): Function and Pain Assessment 109 MIPS CQM Process Y 35 73.7 34.62 - 63.00 63.01 - 86.63 86.64 - 94.37 94.38 - 99.99 -- -- -- 100 No No
Preventive Care and Screening: Influenza Immunization 110 eCQM Process Y 28.1 42 15.50 - 23.63 23.64 - 31.20 31.21 - 38.65 38.66 - 46.76 46.77 - 56.01 56.02 - 67.49 67.50 - 84.98 >= 84.99 No No
Preventive Care and Screening: Influenza Immunization 110 Medicare Part B Claims Process Y 32.3 64.2 29.52 - 41.41 41.42 - 56.31 56.32 - 71.18 71.19 - 82.88 82.89 - 94.14 94.15 - 99.41 99.42 - 99.99 100 No No
Preventive Care and Screening: Influenza Immunization 110 MIPS CQM Process Y 31.4 61.8 29.85 - 41.42 41.43 - 53.84 53.85 - 66.02 66.03 - 76.93 76.94 - 87.80 87.81 - 96.40 96.41 - 99.99 100 No No
Pneumococcal Vaccination Status for Older Adults 111 eCQM Process Y 30.1 50.8 19.01 - 31.06 31.07 - 42.70 42.71 - 53.43 53.44 - 62.85 62.86 - 71.81 71.82 - 80.42 80.43 - 90.40 >= 90.41 No No
Pneumococcal Vaccination Status for Older Adults 111 Medicare Part B Claims Process Y 24.8 71.6 49.76 - 61.10 61.11 - 70.10 70.11 - 77.31 77.32 - 82.95 82.96 - 89.43 89.44 - 95.66 95.67 - 99.99 100 No No
Pneumococcal Vaccination Status for Older Adults 111 MIPS CQM Process Y 28.4 58.4 30.23 - 44.52 44.53 - 55.55 55.56 - 63.63 63.64 - 70.42 70.43 - 76.37 76.38 - 83.76 83.77 - 95.44 >= 95.45 No No
Breast Cancer Screening 112 eCQM Process Y 26.7 48.4 22.28 - 32.74 32.75 - 42.31 42.32 - 51.05 51.06 - 58.43 58.44 - 65.67 65.68 - 73.43 73.44 - 82.30 >= 82.31 No No
Breast Cancer Screening 112 Medicare Part B Claims Process Y 24.7 64.6 44.44 - 52.07 52.08 - 58.44 58.45 - 64.28 64.29 - 70.96 70.97 - 79.84 79.85 - 90.23 90.24 - 99.99 100 No No
Breast Cancer Screening 112 MIPS CQM Process Y 29.3 62.9 35.99 - 48.25 48.26 - 57.57 57.58 - 67.38 67.39 - 75.24 75.25 - 85.30 85.31 - 93.44 93.45 - 99.99 100 No No
Colorectal Cancer Screening 113 eCQM Process Y 28.9 44.4 13.49 - 24.00 24.01 - 33.96 33.97 - 44.38 44.39 - 54.79 54.80 - 64.00 64.01 - 73.37 73.38 - 83.50 >= 83.51 No No
Colorectal Cancer Screening 113 Medicare Part B Claims Process Y 28.9 66.3 36.60 - 50.99 51.00 - 62.49 62.50 - 71.22 71.23 - 79.99 80.00 - 88.63 88.64 - 97.72 97.73 - 99.99 100 No No
Colorectal Cancer Screening 113 MIPS CQM Process Y 30.4 65.3 35.90 - 49.50 49.51 - 60.82 60.83 - 70.87 70.88 - 80.61 80.62 - 90.40 90.41 - 96.97 96.98 - 99.99 100 No No
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 116 MIPS CQM Process Y 27.8 72.6 44.27 - 57.07 57.08 - 72.02 72.03 - 83.77 83.78 - 90.98 90.99 - 95.56 95.57 - 97.54 97.55 - 99.99 100 No No
Diabetes: Eye Exam 117 eCQM Process Y 35.8 60.7 20.61 - 31.99 32.00 - 45.52 45.53 - 66.01 66.02 - 89.11 89.12 - 95.64 95.65 - 98.25 98.26 - 99.72 >= 99.73 No No
Diabetes: Eye Exam 117 Medicare Part B Claims Process Y 24.9 86.9 72.00 - 96.87 96.88 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Diabetes: Eye Exam 117 MIPS CQM Process Y 24.7 85.8 77.26 - 89.99 90.00 - 95.81 95.82 - 98.48 98.49 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) 118 MIPS CQM Process Y 11.1 83.3 76.00 - 78.56 78.57 - 81.07 81.08 - 83.90 83.91 - 86.35 86.36 - 88.72 88.73 - 92.25 92.26 - 98.17 >= 98.18 No No
Diabetes: Medical Attention for Nephropathy 119 eCQM Process Y 19.7 79 67.86 - 74.79 74.80 - 79.99 80.00 - 84.13 84.14 - 87.73 87.74 - 91.10 91.11 - 94.62 94.63 - 98.38 >= 98.39 No No
Diabetes: Medical Attention for Nephropathy 119 MIPS CQM Process Y 20.1 85.1 74.38 - 82.85 82.86 - 87.70 87.71 - 91.93 91.94 - 97.23 97.24 - 99.99 -- -- 100 No No
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation 126 MIPS CQM Process Y 29.3 82.5 66.15 - 85.22 85.23 - 96.42 96.43 - 99.99 -- -- -- -- 100 Yes No
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear 127 MIPS CQM Process Y 27.9 84.8 70.59 - 92.85 92.86 - 99.45 99.46 - 99.99 -- -- -- -- 100 Yes No
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 eCQM Process Y 28.5 45.4 21.15 - 24.58 24.59 - 28.51 28.52 - 34.20 34.21 - 43.84 43.85 - 60.30 60.31 - 78.24 78.25 - 93.28 >= 93.29 No No
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 Medicare Part B Claims Process Y 30.3 74.2 37.52 - 47.77 47.78 - 74.47 74.48 - 95.19 95.20 - 99.26 99.27 - 99.99 -- -- 100 Yes No
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 MIPS CQM Process Y 31.8 72.6 34.35 - 54.25 54.26 - 74.56 74.57 - 90.59 90.60 - 97.55 97.56 - 99.86 99.87 - 99.99 -- 100 No No
Documentation of Current Medications in the Medical Record 130 eCQM Process Y 18.5 90.3 87.55 - 93.48 93.49 - 96.28 96.29 - 97.98 97.99 - 98.99 99.00 - 99.57 99.58 - 99.88 99.89 - 99.99 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Documentation of Current Medications in the Medical Record 130 Medicare Part B Claims Process Y 13.1 96.1 97.95 - 99.51 99.52 - 99.91 99.92 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Documentation of Current Medications in the Medical Record 130 MIPS CQM Process Y 30.5 82.6 68.06 - 90.27 90.28 - 97.23 97.24 - 99.50 99.51 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Pain Assessment and Follow-Up 131 Medicare Part B Claims Process Y 25 87.9 80.57 - 96.91 96.92 - 99.63 99.64 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Pain Assessment and Follow-Up 131 MIPS CQM Process Y 38.2 65.1 15.80 - 39.99 40.00 - 62.78 62.79 - 84.05 84.06 - 95.25 95.26 - 99.54 99.55 - 99.99 -- 100 No No
Preventive Care and Screening: Screening for Depression and Follow-Up Plan 134 eCQM Process Y 32.2 37.1 4.88 - 10.17 10.18 - 17.59 17.60 - 28.28 28.29 - 42.29 42.30 - 56.82 56.83 - 73.29 73.30 - 87.49 >= 87.50 No No
Preventive Care and Screening: Screening for Depression and Follow-Up Plan 134 Medicare Part B Claims Process Y 39.6 69.3 12.94 - 53.91 53.92 - 80.22 80.23 - 96.98 96.99 - 99.99 -- -- -- 100 Yes No
Preventive Care and Screening: Screening for Depression and Follow-Up Plan 134 MIPS CQM Process Y 38.5 67.7 17.11 - 45.64 45.65 - 73.81 73.82 - 90.05 90.06 - 98.49 98.50 - 99.99 -- -- 100 No No
Melanoma: Continuity of Care - Recall System 137 MIPS CQM Structure Y 23 88.6 83.83 - 94.33 94.34 - 98.79 98.80 - 99.99 -- -- -- -- 100 No No
Melanoma: Coordination of Care 138 MIPS CQM Process Y 30.2 75.8 49.44 - 63.63 63.64 - 78.25 78.26 - 92.58 92.59 - 99.99 -- -- -- 100 No No
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 141 Medicare Part B Claims Outcome Y 10.8 97.6 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 141 MIPS CQM Outcome Y 26.4 84.8 73.85 - 87.49 87.50 - 96.29 96.30 - 99.30 99.31 - 99.99 -- -- -- 100 No No
Oncology: Medical and Radiation - Pain Intensity Quantified 143 eCQM Process Y 25.4 84.9 77.21 - 87.78 87.79 - 94.91 94.92 - 97.26 97.27 - 98.34 98.35 - 99.45 99.46 - 99.99 -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Oncology: Medical and Radiation - Pain Intensity Quantified 143 MIPS CQM Process Y 17.1 91.9 90.31 - 95.39 95.40 - 97.12 97.13 - 98.56 98.57 - 99.25 99.26 - 99.99 -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Oncology: Medical and Radiation - Plan of Care for Pain 144 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy 145 Medicare Part B Claims Process Y 26.5 81.9 66.41 - 82.92 82.93 - 90.90 90.91 - 95.17 95.18 - 97.39 97.40 - 99.06 99.07 - 99.99 -- 100 Yes No
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy 145 MIPS CQM Process Y 24.9 85.1 73.10 - 88.03 88.04 - 94.91 94.92 - 98.15 98.16 - 99.53 99.54 - 99.99 -- -- 100 Yes No
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms 146 Medicare Part B Claims Process Y 1.2 0.3 0.23 - 0.01 -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms 146 MIPS CQM Process Y 3.5 0.5 0.24 - 0.12 0.11 - 0.05 0.04 - 0.01 -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy 147 Medicare Part B Claims Process Y 22.3 86.2 76.47 - 87.17 87.18 - 94.05 94.06 - 97.00 97.01 - 99.99 -- -- -- 100 Yes No
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy 147 MIPS CQM Process Y 13.7 94.1 93.04 - 97.96 97.97 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Falls: Risk Assessment 154 Medicare Part B Claims Process Y 18.3 94 96.95 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Falls: Risk Assessment 154 MIPS CQM Process Y 35.4 73.2 28.63 - 60.81 60.82 - 84.99 85.00 - 95.96 95.97 - 99.73 99.74 - 99.99 -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Falls: Plan of Care 155 Medicare Part B Claims Process Y 30.8 81.4 55.81 - 84.61 84.62 - 99.20 99.21 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Falls: Plan of Care 155 MIPS CQM Process Y 28.8 82.7 67.86 - 86.78 86.79 - 94.99 95.00 - 98.21 98.22 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis 160 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Coronary Artery Bypass Graft (CABG): Prolonged Intubation 164 MIPS CQM Outcome Y 5.9 7.6 11.40 - 9.10 9.09 - 7.70 7.69 - 6.81 6.80 - 5.56 5.55 - 4.29 4.28 - 3.09 3.08 - 1.55 <= 1.54 No No
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate 165 MIPS CQM Outcome Y 1.1 0.5 0.84 - 0.01 -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Coronary Artery Bypass Graft (CABG): Stroke 166 MIPS CQM Outcome Y 1.6 1.3 2.38 - 1.80 1.79 - 1.27 1.26 - 0.72 0.71 - 0.01 -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure 167 MIPS CQM Outcome Y 2.6 2.2 3.51 - 2.71 2.70 - 2.16 2.15 - 1.86 1.85 - 1.29 1.28 - 0.89 0.88 - 0.01 -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration 168 MIPS CQM Outcome Y 2.6 2.4 3.95 - 3.14 3.13 - 2.64 2.63 - 1.80 1.79 - 1.28 1.27 - 0.88 0.87 - 0.01 -- 0 Yes No
Rheumatoid Arthritis (RA): Tuberculosis Screening 176 MIPS CQM Process Y 31 65.4 32.00 - 48.14 48.15 - 55.55 55.56 - 68.00 68.01 - 80.42 80.43 - 99.03 99.04 - 99.99 -- 100 No No
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity 177 MIPS CQM Process Y 29.4 79 57.23 - 74.99 75.00 - 88.23 88.24 - 96.01 96.02 - 99.99 -- -- -- 100 Yes No
Rheumatoid Arthritis (RA): Functional Status Assessment 178 MIPS CQM Process Y 27.2 82 67.61 - 81.39 81.40 - 90.58 90.59 - 95.94 95.95 - 99.99 -- -- -- 100 Yes No
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis 179 MIPS CQM Process Y 30.9 76.7 44.53 - 67.88 67.89 - 85.30 85.31 - 95.21 95.22 - 99.99 -- -- -- 100 Yes No
Rheumatoid Arthritis (RA): Glucocorticoid Management 180 MIPS CQM Process Y 28.6 79.3 52.68 - 75.78 75.79 - 87.95 87.96 - 95.05 95.06 - 99.57 99.58 - 99.99 -- -- 100 Yes No
Elder Maltreatment Screen and Follow-Up Plan 181 Medicare Part B Claims Process Y 34.6 80.9 55.38 - 97.31 97.32 - 99.55 99.56 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Elder Maltreatment Screen and Follow-Up Plan 181 MIPS CQM Process Y 29.9 75.6 50.65 - 66.03 66.04 - 77.77 77.78 - 89.28 89.29 - 96.78 96.79 - 99.99 -- -- 100 No No
Functional Outcome Assessment 182 Medicare Part B Claims Process Y 14.7 96.7 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Functional Outcome Assessment 182 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use 185 Medicare Part B Claims Process Y 8.5 97.8 98.57 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use 185 MIPS CQM Process Y 25.8 82 61.64 - 84.99 85.00 - 90.53 90.54 - 95.41 95.42 - 98.40 98.41 - 99.99 -- -- 100 Yes No
Stroke and Stroke Rehabilitation: Thrombolytic Therapy 187 MIPS CQM Process Y 20.5 90.1 88.89 - 96.48 96.49 - 99.99 -- -- -- -- -- 100 Yes No
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery 191 eCQM Outcome Y 18.4 88.5 85.25 - 90.62 90.63 - 93.40 93.41 - 95.58 95.59 - 96.87 96.88 - 97.82 97.83 - 98.77 98.78 - 99.99 100 No No
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery 191 MIPS CQM Outcome Y 9.3 96.1 94.37 - 96.87 96.88 - 98.97 98.98 - 99.99 -- -- -- -- 100 Yes No
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures 192 eCQM Outcome Y 0.9 0.2 -- -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures 192 MIPS CQM Outcome Y 6.5 0.9 -- -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Radiology: Stenosis Measurement in Carotid Imaging Reports 195 Medicare Part B Claims Process Y 16.1 92.7 91.72 - 96.22 96.23 - 98.17 98.18 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Radiology: Stenosis Measurement in Carotid Imaging Reports 195 MIPS CQM Process Y 10.7 96.6 97.81 - 99.84 99.85 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis 205 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Knee Impairments 217 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Hip Impairments 218 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Foot or Ankle Impairments 219 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Lumbar Impairments 220 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Shoulder Impairments 221 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments 222 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Status Change for Patients with Other General Orthopaedic Impairments 223 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Radiology: Reminder System for Screening Mammograms 225 Medicare Part B Claims Structure Y 19.3 94.3 99.36 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Radiology: Reminder System for Screening Mammograms 225 MIPS CQM Structure Y 13.8 97.4 -- -- -- -- -- -- -- 100 Yes No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Controlling High Blood Pressure 236 eCQM Intermediate Outcome Y 16.6 63 51.46 - 56.82 56.83 - 60.94 60.95 - 64.67 64.68 - 68.17 68.18 - 72.00 72.01 - 76.25 76.26 - 82.20 >= 82.21 No No
Controlling High Blood Pressure 236 Medicare Part B Claims Intermediate Outcome Y 18.6 72.2 58.57 - 63.97 63.98 - 68.82 68.83 - 73.90 73.91 - 78.56 78.57 - 83.32 83.33 - 88.31 88.32 - 94.88 >= 94.89 No No
Controlling High Blood Pressure 236 MIPS CQM Intermediate Outcome Y 24.1 69.3 52.41 - 60.04 60.05 - 65.67 65.68 - 70.61 70.62 - 76.82 76.83 - 84.61 84.62 - 93.39 93.40 - 99.99 100 No No
Use of High-Risk Medications in the Elderly 238 eCQM Process Y 9 4.7 8.04 - 4.75 4.74 - 2.68 2.67 - 1.32 1.31 - 0.54 0.53 - 0.05 0.04 - 0.01 -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Use of High-Risk Medications in the Elderly 238 MIPS CQM Process Y 6.6 1.7 0.68 - 0.29 0.28 - 0.14 0.13 - 0.01 -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 239 eCQM Process Y 19.9 37.6 26.23 - 29.51 29.52 - 31.47 31.48 - 32.79 32.80 - 33.85 33.86 - 38.72 38.73 - 47.76 47.77 - 65.52 >= 65.53 No No
Childhood Immunization Status 240 eCQM Process Y 17.3 26.9 9.30 - 14.80 14.81 - 20.49 20.50 - 26.67 26.68 - 30.66 30.67 - 37.22 37.23 - 42.41 42.42 - 50.88 >= 50.89 No No
Cardiac Rehabilitation Patient Referral from an Outpatient Setting 243 MIPS CQM Process Y 20.1 22.2 8.11 - 11.87 11.88 - 14.62 14.63 - 17.22 17.23 - 20.77 20.78 - 24.31 24.32 - 30.68 30.69 - 44.43 >= 44.44 No No
Barrett's Esophagus 249 Medicare Part B Claims Process Y 0.2 100 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Barrett's Esophagus 249 MIPS CQM Process Y 4.1 99.5 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Radical Prostatectomy Pathology Reporting 250 Medicare Part B Claims Process Y 0.7 99.9 -- -- -- -- -- -- -- 100 Yes No
Radical Prostatectomy Pathology Reporting 250 MIPS CQM Process Y 1.5 99.7 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain 254 MIPS CQM Process Y 15.3 85.1 74.42 - 80.94 80.95 - 85.36 85.37 - 88.88 88.89 - 91.99 92.00 - 95.23 95.24 - 97.66 97.67 - 99.99 100 No No
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain 254 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure 255 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure 255 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
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 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
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 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) 260 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 261 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 261 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Image Confirmation of Successful Excision of Image-Localized Breast Lesion 262 MIPS CQM Process Y 0.2 100 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Sentinel Lymph Node Biopsy for Invasive Breast Cancer 264 MIPS CQM Process Y 6.1 98 97.96 - 99.21 99.22 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Biopsy Follow-Up 265 MIPS CQM Process Y 29.5 81.8 61.23 - 83.62 83.63 - 95.64 95.65 - 99.37 99.38 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy 268 MIPS CQM Process Y 35.9 65 32.00 - 45.34 45.35 - 57.13 57.14 - 78.56 78.57 - 95.99 96.00 - 99.06 99.07 - 99.99 -- 100 No No
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy 268 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment 271 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy 275 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Sleep Apnea: Severity Assessment at Initial Diagnosis 277 MIPS CQM Process Y 26.9 82.1 69.01 - 81.02 81.03 - 90.62 90.63 - 99.70 99.71 - 99.99 -- -- -- 100 Yes No
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy 279 MIPS CQM Process Y 17.8 92 90.08 - 96.26 96.27 - 99.16 99.17 - 99.99 -- -- -- -- 100 Yes No
Dementia: Cognitive Assessment 281 eCQM Process Y 35.7 46.1 5.88 - 12.89 12.90 - 26.08 26.09 - 44.99 45.00 - 59.25 59.26 - 73.32 73.33 - 88.56 88.57 - 96.76 >= 96.77 No No
Dementia: Functional Status Assessment 282 MIPS CQM Process Y 32.2 79.2 57.14 - 78.94 78.95 - 95.27 95.28 - 99.12 99.13 - 99.99 -- -- -- 100 Yes No
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management 283 MIPS CQM Process Y 29.9 81.3 58.14 - 83.07 83.08 - 96.66 96.67 - 99.81 99.82 - 99.99 -- -- -- 100 Yes No
Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia 286 MIPS CQM Process Y 27.3 82 62.86 - 78.68 78.69 - 89.88 89.89 - 98.20 98.21 - 99.99 -- -- -- 100 Yes No
Dementia: Caregiver Education and Support 288 MIPS CQM Process Y 27.9 80.9 59.26 - 77.32 77.33 - 89.32 89.33 - 97.53 97.54 - 99.99 -- -- -- 100 Yes No
Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease 290 MIPS CQM Process Y 19.2 89.7 85.09 - 92.55 92.56 - 96.91 96.92 - 99.22 99.23 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment 291 MIPS CQM Process Y 13.1 93.3 86.49 - 94.99 95.00 - 99.99 -- -- -- -- -- 100 Yes No
Parkinson's Disease: Rehabilitative Therapy Options 293 MIPS CQM Process Y 19.8 86.6 67.03 - 82.94 82.95 - 94.28 94.29 - 99.99 -- -- -- -- 100 Yes No
Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery 303 MIPS CQM Patient Reported Outcome Y 30.5 74 45.11 - 70.87 70.88 - 78.76 78.77 - 84.90 84.91 - 91.77 91.78 - 98.79 98.80 - 99.99 -- 100 No No
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery 304 MIPS CQM Patient Engagement Experience Y 28.4 76.6 50.00 - 72.21 72.22 - 80.29 80.30 - 87.08 87.09 - 95.41 95.42 - 99.11 99.12 - 99.99 -- 100 No No
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 305 eCQM Process Y 6.2 3.3 0.31 - 0.41 0.42 - 0.67 0.68 - 1.02 1.03 - 1.34 1.35 - 2.23 2.24 - 3.84 3.85 - 6.90 >= 6.91 No No
Cervical Cancer Screening 309 eCQM Process Y 25.6 35.1 9.83 - 16.79 16.80 - 23.65 23.66 - 31.53 31.54 - 39.71 39.72 - 48.30 48.31 - 57.62 57.63 - 72.60 >= 72.61 No No
Chlamydia Screening for Women 310 eCQM Process Y 20.2 35.2 16.67 - 22.30 22.31 - 28.04 28.05 - 33.32 33.33 - 39.12 39.13 - 44.77 44.78 - 53.13 53.14 - 63.77 >= 63.78 No No
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 317 eCQM Process Y 23.6 37.3 19.56 - 24.13 24.14 - 28.18 28.19 - 32.30 32.31 - 36.66 36.67 - 42.11 42.12 - 50.69 50.70 - 74.54 >= 74.55 No No
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 317 Medicare Part B Claims Process Y 30.1 68 34.25 - 45.47 45.48 - 58.48 58.49 - 73.28 73.29 - 89.40 89.41 - 98.06 98.07 - 99.99 -- 100 No No
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 317 MIPS CQM Process Y 32.7 54.1 25.75 - 30.80 30.81 - 35.46 35.47 - 42.56 42.57 - 59.14 59.15 - 83.48 83.49 - 97.31 97.32 - 99.99 100 No No
Falls: Screening for Future Fall Risk 318 eCQM Process Y 35.4 49.8 7.24 - 20.26 20.27 - 36.40 36.41 - 52.24 52.25 - 66.72 66.73 - 78.59 78.60 - 88.50 88.51 - 96.55 >= 96.56 No No
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 320 Medicare Part B Claims Process Y 21.1 91.8 95.24 - 97.72 97.73 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 320 MIPS CQM Process Y 19.5 88.9 85.00 - 89.73 89.74 - 93.60 93.61 - 95.94 95.95 - 97.72 97.73 - 98.95 98.96 - 99.99 -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients 322 MIPS CQM Efficiency Y 16.9 4.1 1.90 - 0.01 -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) 323 MIPS CQM Efficiency Y 16.9 4.4 2.44 - 0.01 -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients 324 MIPS CQM Efficiency Y 13.4 5.1 6.25 - 2.02 2.01 - 0.01 -- -- -- -- -- 0 Yes No
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions 325 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy 326 Medicare Part B Claims Process Y 20.6 89.5 84.13 - 95.28 95.29 - 98.79 98.80 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy 326 MIPS CQM Process Y 18 81.2 69.54 - 75.10 75.11 - 78.89 78.90 - 83.08 83.09 - 88.16 88.17 - 94.93 94.94 - 99.99 -- 100 No No
Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL 328 MIPS CQM Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis 329 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days 330 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) 331 MIPS CQM Process Y 34.5 61.5 92.15 - 87.51 87.50 - 82.89 82.88 - 75.37 75.36 - 64.36 64.35 - 46.68 46.67 - 20.00 19.99 - 0.01 0 No No
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) 332 MIPS CQM Process Y 15.4 93.2 93.55 - 96.19 96.20 - 97.58 97.59 - 98.39 98.40 - 99.35 99.36 - 99.99 -- -- 100 Yes No
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) 333 MIPS CQM Efficiency Y 6.7 2.2 2.50 - 0.91 0.90 - 0.27 0.26 - 0.01 -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) 335 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Maternity Care: Post-Partum Follow-Up and Care Coordination 336 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier 337 MIPS CQM Process Y 30 72.1 47.06 - 60.60 60.61 - 73.62 73.63 - 82.50 82.51 - 89.99 90.00 - 96.42 96.43 - 99.99 -- 100 No No
HIV Viral Load Suppression 338 MIPS CQM Outcome Y 24.2 80.9 74.47 - 78.56 78.57 - 83.99 84.00 - 87.93 87.94 - 93.99 94.00 - 97.23 97.24 - 99.99 -- 100 No No
HIV Medical Visit Frequency 340 MIPS CQM Process Y 25.8 71.5 48.97 - 52.85 52.86 - 61.08 61.09 - 82.68 82.69 - 87.99 88.00 - 92.85 92.86 - 95.91 95.92 - 99.99 100 No No
Pain Brought Under Control Within 48 Hours 342 MIPS CQM Outcome Y 9.2 96.6 98.78 - 99.99 -- -- -- -- -- -- 100 Yes No
Screening Colonoscopy Adenoma Detection Rate 343 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) 344 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive 345 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive 346 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive 347 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate 348 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy 350 MIPS CQM Process Y 14.8 94.4 96.00 - 99.99 -- -- -- -- -- -- 100 Yes No
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation 351 MIPS CQM Process Y 16.7 95.3 -- -- -- -- -- -- -- 100 Yes No
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet 352 MIPS CQM Process Y 4.8 98.8 -- -- -- -- -- -- -- 100 Yes No
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report 353 MIPS CQM Process Y 6.3 98.6 -- -- -- -- -- -- -- 100 Yes No
Anastomotic Leak Intervention 354 MIPS CQM Outcome Y 4.1 2.2 3.61 - 3.24 3.23 - 0.74 0.73 - 0.01 -- -- -- -- 0 Yes No
Unplanned Reoperation within the 30 Day Postoperative Period 355 MIPS CQM Outcome Y 11.9 3.5 3.15 - 2.28 2.27 - 1.22 1.21 - 0.41 0.40 - 0.01 -- -- -- 0 Yes No
Unplanned Hospital Readmission within 30 Days of Principal Procedure 356 MIPS CQM Outcome Y 14.5 5 5.00 - 3.31 3.30 - 2.01 2.00 - 0.01 -- -- -- -- 0 Yes No
Surgical Site Infection (SSI) 357 MIPS CQM Outcome Y 16.1 4.8 3.48 - 2.28 2.27 - 0.94 0.93 - 0.01 -- -- -- -- 0 Yes No
Patient-Centered Surgical Risk Assessment and Communication 358 MIPS CQM Process Y 38.6 72.2 17.29 - 61.78 61.79 - 91.42 91.43 - 97.63 97.64 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies 360 MIPS CQM Process Y 34.1 75.9 31.53 - 61.37 61.38 - 90.54 90.55 - 98.82 98.83 - 99.99 -- -- -- 100 Yes No
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry 361 MIPS CQM Structure Y 14.3 96.5 -- -- -- -- -- -- -- 100 Yes No
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison 362 MIPS CQM Structure Y 21.9 94.4 -- -- -- -- -- -- -- 100 Yes No
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines 364 MIPS CQM Process Y 25.3 84.6 59.02 - 93.24 93.25 - 97.64 97.65 - 99.80 99.81 - 99.99 -- -- -- 100 Yes No
Follow-Up Care for Children Prescribed ADHD Medication (ADD) 366 eCQM Process Y 16.4 40.2 26.67 - 30.86 30.87 - 33.95 33.96 - 38.09 38.10 - 46.45 46.46 - 48.83 48.84 - 54.54 54.55 - 65.90 >= 65.91 No No
Depression Remission at Twelve Months 370 eCQM Outcome Y 9.7 7.1 2.08 - 2.69 2.70 - 3.69 3.70 - 4.34 4.35 - 5.31 5.32 - 7.13 7.14 - 8.76 8.77 - 14.99 >= 15.00 No No
Depression Remission at Twelve Months 370 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Depression Utilization of the PHQ-9 Tool 371 eCQM Process Y 19.1 18.6 3.82 - 6.11 6.12 - 9.08 9.09 - 12.68 12.69 - 16.66 16.67 - 22.08 22.09 - 30.29 30.30 - 43.13 >= 43.14 No No
Maternal Depression Screening 372 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Closing the Referral Loop: Receipt of Specialist Report 374 eCQM Process Y 31.7 41.2 7.63 - 14.97 14.98 - 26.32 26.33 - 36.73 36.74 - 48.14 48.15 - 60.24 60.25 - 74.43 74.44 - 90.74 >= 90.75 No No
Closing the Referral Loop: Receipt of Specialist Report 374 MIPS CQM Process Y 40 53.1 6.77 - 8.50 8.51 - 37.83 37.84 - 62.85 62.86 - 82.42 82.43 - 88.88 88.89 - 92.73 92.74 - 99.01 >= 99.02 No No
Functional Status Assessment for Total Knee Replacement 375 eCQM Process Y 27.7 29 5.00 - 9.67 9.68 - 15.90 15.91 - 20.30 20.31 - 24.55 24.56 - 34.37 34.38 - 53.41 53.42 - 77.26 >= 77.27 No No
Functional Status Assessment for Total Hip Replacement 376 eCQM Process Y 24.5 26.5 4.82 - 8.50 8.51 - 13.09 13.10 - 19.22 19.23 - 27.58 27.59 - 33.32 33.33 - 40.18 40.19 - 63.48 >= 63.49 No No
Functional Status Assessments for Congestive Heart Failure 377 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Children Who Have Dental Decay or Cavities 378 eCQM Outcome Y 1.6 0.4 0.47 - 0.10 0.09 - 0.01 -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists 379 eCQM Process Y 7.4 3.6 0.32 - 0.54 0.55 - 0.73 0.74 - 1.08 1.09 - 2.07 2.08 - 3.21 3.22 - 4.89 4.90 - 9.04 >= 9.05 No No
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment 382 eCQM Process Y 23.8 22.8 3.43 - 7.00 7.01 - 12.46 12.47 - 14.83 14.84 - 20.25 20.26 - 29.00 29.01 - 36.10 36.11 - 51.71 >= 51.72 No No
Adherence to Antipsychotic Medications For Individuals with Schizophrenia 383 MIPS CQM Intermediate Outcome Y 21.1 82.1 58.00 - 71.42 71.43 - 86.83 86.84 - 90.00 90.01 - 98.32 98.33 - 99.99 -- -- 100 No No
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery 384 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery 385 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences 386 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users 387 MIPS CQM Process Y 20.5 7.1 0.38 - 0.45 0.46 - 0.58 0.59 - 0.76 0.77 - 1.31 1.32 - 1.40 1.41 - 1.60 1.61 - 2.86 >= 2.87 No No
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) 388 MIPS CQM Outcome Y 4.8 0.4 -- -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Cataract Surgery: Difference Between Planned and Final Refraction 389 MIPS CQM Outcome Y 22.4 87.6 77.17 - 90.90 90.91 - 96.96 96.97 - 99.21 99.22 - 99.99 -- -- -- 100 No No
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options 390 MIPS CQM Process Y 24.1 84.2 63.64 - 80.86 80.87 - 95.44 95.45 - 99.99 -- -- -- -- 100 Yes No
Follow-Up After Hospitalization for Mental Illness (FUH) 391 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation 392 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision 393 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Immunizations for Adolescents 394 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Lung Cancer Reporting (Biopsy/Cytology Specimens) 395 Medicare Part B Claims Process Y 3.7 98.9 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Lung Cancer Reporting (Biopsy/Cytology Specimens) 395 MIPS CQM Process Y 9.7 98 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Lung Cancer Reporting (Resection Specimens) 396 MIPS CQM Process Y 0.5 99.9 -- -- -- -- -- -- -- 100 Yes No
Lung Cancer Reporting (Resection Specimens) 396 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Melanoma Reporting 397 Medicare Part B Claims Process Y 2.6 99.2 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Melanoma Reporting 397 MIPS CQM Process Y 25.6 89.5 91.96 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Optimal Asthma Control 398 MIPS CQM Outcome Y 33.8 71.9 33.52 - 59.45 59.46 - 74.99 75.00 - 95.99 96.00 - 98.98 98.99 - 99.99 -- -- 100 No No
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk 400 MIPS CQM Process Y 28.6 20.9 1.26 - 1.84 1.85 - 3.22 3.23 - 6.30 6.31 - 16.77 16.78 - 24.10 24.11 - 32.00 32.01 - 74.59 >= 74.60 No No
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis 401 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Tobacco Use and Help with Quitting Among Adolescents 402 MIPS CQM Process Y 13.8 91.2 86.36 - 91.17 91.18 - 94.11 94.12 - 96.11 96.12 - 97.58 97.59 - 98.83 98.84 - 99.99 -- 100 Yes No
Adult Kidney Disease: Referral to Hospice 403 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Anesthesiology Smoking Abstinence 404 MIPS CQM Intermediate Outcome Y 24.2 61.2 39.88 - 50.58 50.59 - 57.24 57.25 - 62.99 63.00 - 69.74 69.75 - 75.26 75.27 - 82.40 82.41 - 93.37 >= 93.38 No No
Appropriate Follow-up Imaging for Incidental Abdominal Lesions 405 Medicare Part B Claims Process Y 16.7 7.8 10.26 - 4.45 4.44 - 0.73 0.72 - 0.01 -- -- -- -- 0 Yes No
Appropriate Follow-up Imaging for Incidental Abdominal Lesions 405 MIPS CQM Process Y 9.8 5.8 12.11 - 6.68 6.67 - 2.64 2.63 - 0.54 0.53 - 0.01 -- -- -- 0 Yes No
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients 406 Medicare Part B Claims Process Y 34.7 31.2 61.90 - 48.01 48.00 - 37.51 37.50 - 15.57 15.56 - 2.57 2.56 - 0.01 -- -- 0 No No
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients 406 MIPS CQM Process Y 18.2 9.4 14.94 - 5.98 5.97 - 3.65 3.64 - 0.10 0.09 - 0.01 -- -- -- 0 Yes No
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia 407 MIPS CQM Process Y 4.8 98.7 -- -- -- -- -- -- -- 100 Yes No
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia 407 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Opioid Therapy Follow-up Evaluation 408 MIPS CQM Process Y 29.8 83.1 68.35 - 91.35 91.36 - 98.48 98.49 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Clinical Outcome Post Endovascular Stroke Treatment 409 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Psoriasis: Clinical Response to Oral Systemic or Biologic Medications 410 MIPS CQM Outcome Y 32.8 59.2 23.08 - 36.35 36.36 - 49.99 50.00 - 61.53 61.54 - 72.21 72.22 - 87.49 87.50 - 97.21 97.22 - 99.99 100 No No
Depression Remission at Six Months 411 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Documentation of Signed Opioid Treatment Agreement 412 MIPS CQM Process Y 32.2 81.1 61.17 - 88.34 88.35 - 97.43 97.44 - 99.66 99.67 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Door to Puncture Time for Endovascular Stroke Treatment 413 MIPS CQM Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Evaluation or Interview for Risk of Opioid Misuse 414 MIPS CQM Process Y 21.3 91.1 88.55 - 98.59 98.60 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older 415 Medicare Part B Claims Efficiency Y 3.6 98.2 96.00 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older 415 MIPS CQM Efficiency Y 14.9 77.7 63.41 - 69.99 70.00 - 76.18 76.19 - 80.36 80.37 - 83.45 83.46 - 86.48 86.49 - 89.60 89.61 - 98.20 >= 98.21 No No
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years 416 MIPS CQM Efficiency Y 17.8 30.5 46.67 - 40.01 40.00 - 35.01 35.00 - 28.38 28.37 - 22.82 22.81 - 18.76 18.75 - 14.82 14.81 - 9.53 <= 9.52 No No
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years 416 Medicare Part B Claims Efficiency N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive 417 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Osteoporosis Management in Women Who Had a Fracture 418 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Osteoporosis Management in Women Who Had a Fracture 418 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Overuse of Imaging for the Evaluation of Primary Headache 419 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Overuse of Imaging for the Evaluation of Primary Headache 419 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey 420 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal 421 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury 422 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury 422 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Perioperative Temperature Management 424 MIPS CQM Outcome Y 8.9 97.2 98.46 - 99.51 99.52 - 99.74 99.75 - 99.87 99.88 - 99.99 -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Photodocumentation of Cecal Intubation 425 Medicare Part B Claims Process Y 15.6 94.7 97.44 - 98.48 98.49 - 99.15 99.16 - 99.99 -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Photodocumentation of Cecal Intubation 425 MIPS CQM Process Y 4.4 98.1 97.59 - 98.31 98.32 - 98.73 98.74 - 99.04 99.05 - 99.29 99.30 - 99.50 99.51 - 99.76 99.77 - 99.99 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence 428 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy 429 Medicare Part B Claims Process N -- -- -- -- -- -- -- -- -- -- -- No
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy 429 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy 430 MIPS CQM Process Y 13.2 94.3 93.66 - 97.17 97.18 - 98.53 98.54 - 99.21 99.22 - 99.63 99.64 - 99.91 99.92 - 99.99 -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling 431 MIPS CQM Process Y 33 66.4 33.43 - 49.34 49.35 - 66.11 66.12 - 78.12 78.13 - 86.99 87.00 - 93.51 93.52 - 97.95 97.96 - 99.99 100 No No
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair 432 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair 433 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair 434 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Quality of Life Assessment For Patients With Primary Headache Disorders 435 MIPS CQM Patient Reported Outcome Y 42.3 38.3 2.05 - 3.02 3.03 - 5.49 5.50 - 12.43 12.44 - 25.81 25.82 - 75.85 75.86 - 99.99 -- 100 No No
Quality of Life Assessment For Patients With Primary Headache Disorders 435 Medicare Part B Claims Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques 436 Medicare Part B Claims Process Y 23.3 88.4 85.73 - 94.12 94.13 - 97.45 97.46 - 98.95 98.96 - 99.65 99.66 - 99.99 -- -- 100 Yes No
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques 436 MIPS CQM Process Y 20.2 92 93.28 - 96.96 96.97 - 99.05 99.06 - 99.66 99.67 - 99.91 99.92 - 99.99 -- -- 100 Yes No
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure 437 Medicare Part B Claims Outcome Y 6.6 2 1.32 - 0.56 0.55 - 0.01 -- -- -- -- -- 0 Yes No
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure 437 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 438 eCQM Process Y 19.1 82.2 63.75 - 71.06 71.07 - 77.11 77.12 - 84.26 84.27 - 99.99 -- -- -- 100 No No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 438 MIPS CQM Process Y 16.9 89.8 78.72 - 91.66 91.67 - 95.64 95.65 - 97.37 97.38 - 99.99 -- -- -- 100 Yes No
Age Appropriate Screening Colonoscopy 439 MIPS CQM Efficiency N -- -- -- -- -- -- -- -- -- -- -- No
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician 440 MIPS CQM Process Y 21.1 92.2 96.91 - 98.95 98.96 - 99.87 99.88 - 99.99 -- -- -- -- 100 Yes No
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) 441 MIPS CQM Intermediate Outcome Y 13.4 42.9 32.40 - 37.13 37.14 - 40.16 40.17 - 44.03 44.04 - 47.77 47.78 - 50.61 50.62 - 54.35 54.36 - 58.25 >= 58.26 No No
Persistence of Beta-Blocker Treatment After a Heart Attack 442 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Non-Recommended Cervical Cancer Screening in Adolescent Females 443 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Medication Management for People with Asthma 444 MIPS CQM Process Y 12.6 94.3 91.67 - 95.99 96.00 - 97.77 97.78 - 98.43 98.44 - 99.99 -- -- -- 100 Yes No
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) 445 MIPS CQM Outcome Y 2.2 2.5 3.90 - 3.17 3.16 - 2.69 2.68 - 2.25 2.24 - 1.73 1.72 - 1.23 1.22 - 0.01 -- 0 No No
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories 446 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Work Up Prior to Endometrial Ablation 448 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies 449 MIPS CQM Process Y 5.4 97.4 95.71 - 98.52 98.53 - 99.99 -- -- -- -- -- 100 Yes No
Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy 450 MIPS CQM Process Y 23.7 87.4 90.00 - 90.90 90.91 - 93.54 93.55 - 99.99 -- -- -- -- 100 Yes No
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 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) 4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies 452 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Proportion Receiving Chemotherapy in the Last 14 Days of Life 453 MIPS CQM Process Y 6.3 8.9 15.00 - 10.43 10.42 - 9.19 9.18 - 8.00 7.99 - 7.36 7.35 - 7.04 7.03 - 2.39 2.38 - 0.01 0 No No
Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life 454 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life 455 MIPS CQM Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Proportion Not Admitted To Hospice 456 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Proportion Admitted to Hospice for less than 3 days 457 MIPS CQM Outcome Y 7.6 10.7 15.38 - 15.01 15.00 - 13.52 13.51 - 11.11 11.10 - 9.65 9.64 - 6.46 6.45 - 0.01 -- 0 No No
Average Change in Back Pain following Lumbar Discectomy / Laminotomy 459 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Average Change in Back Pain following Lumbar Fusion 460 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy 461 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy 462 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) 463 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use 464 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and.Interrogation of Ovarian Arteries 465 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Developmental Screening in the First Three Years of Life 467 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) 468 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Average Change in Functional Status Following Lumbar Fusion Surgery 469 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Average Change In Functional Status Following Total Knee Replacement Surgery 470 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery 471 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture 472 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Average Change in Leg Pain Following Lumbar Fusion Surgery 473 MIPS CQM Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Zoster (Shingles) Vaccination 474 MIPS CQM Process N -- -- -- -- -- -- -- -- -- -- -- No
HIV Screening 475 eCQM Process N -- -- -- -- -- -- -- -- -- -- -- No
Asthma Assessment and Classification AAAAI11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Lung Function/Spirometry Evaluation AAAAI12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Asthma Control: Minimal Important Difference Improvement AAAAI17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Penicillin Allergy: Appropriate Removal or Confirmation AAAAI18 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Asthma: Assessment of Asthma Control – Ambulatory Care Setting AAAAI2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Documentation of Clinical Response to Allergen Immunotherapy within One Year AAAAI6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year AAAAI8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy Injection(s) AAAAI9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Psoriasis: Assessment of Psoriasis Disease Activity AAD1 QCDR measure Process Y 33 42.5 10.16 - 18.74 18.75 - 25.12 25.13 - 35.83 35.84 - 43.47 43.48 - 57.07 57.08 - 76.76 76.77 - 99.99 100 No No
Psoriasis: Screening for Psoriatic Arthritis AAD2 QCDR measure Process Y 23.9 87.6 82.44 - 95.44 95.45 - 99.99 -- -- -- -- -- 100 Yes No
Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients AAD3 QCDR measure Process Y 2.1 1 1.58 - 0.01 -- -- -- -- -- -- 0 Yes No
Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk AAD4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Biopsy: Reporting Time - Clinician to Patient AAD5 QCDR measure Process Y 23 87 73.58 - 90.13 90.14 - 98.61 98.62 - 99.99 -- -- -- -- 100 Yes No
Diabetes/Pre-Diabetes Screening for Patients with DSP AAN1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Falls screening (aggregation of AAN disease specific falls measures) AAN10 QCDR measure Process Y 34.3 42.1 4.09 - 11.95 11.96 - 22.21 22.22 - 30.42 30.43 - 53.84 53.85 - 65.26 65.27 - 81.94 81.95 - 90.33 >= 90.34 No No
Overuse of barbiturate and opioid containing medications for primary headache disorders AAN11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Quality of Life Assessment for Patients with Epilepsy AAN12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Current MS Disability Scale Score AAN14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Quality of Life Assessment AAN15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Falls Outcome for Patients with Parkinson's Disease AAN16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
First line treatment for infantile spasms (IS) AAN18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Botulinum Toxin Serotype A (BoNT-A) for spasticity or dystonia AAN19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
DSP Screening for Unhealthy Alcohol Use AAN2 QCDR measure Process Y 9.7 48.4 42.45 - 46.26 46.27 - 47.02 47.03 - 49.31 49.32 - 52.30 52.31 - 53.46 53.47 - 55.12 55.13 - 59.18 >= 59.19 No No
Querying for co-morbid conditions of tic disorder (TD) and Tourette syndrome (TS) AAN20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Screening for Psychiatric or Behavioral Health Disorders AAN4 QCDR measure Process Y 32.3 64.4 27.59 - 41.34 41.35 - 58.32 58.33 - 74.06 74.07 - 83.90 83.91 - 94.11 94.12 - 98.13 98.14 - 99.73 >= 99.74 No No
MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK AAN5 QCDR measure Process Y 16.6 30.1 14.50 - 16.66 16.67 - 22.40 22.41 - 28.43 28.44 - 32.46 32.47 - 40.19 40.20 - 45.50 45.51 - 53.00 >= 53.01 No No
Exercise and Appropriate Physical Activity Counseling for Patients with MS AAN8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease AAN9 QCDR measure Process Y 30.2 79.9 61.54 - 82.60 82.61 - 92.85 92.86 - 94.58 94.59 - 97.49 97.50 - 99.99 -- -- 100 No No
Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids AAO11 QCDR measure Process Y 1.4 99.5 99.60 - 99.99 -- -- -- -- -- -- 100 Yes No
Topical Ear Drop Monotherapy for Children with Acute Tympanostomy Tube Otorrhea AAO12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan for Bell’s Palsy (Inverse Measure) AAO13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Inappropriate Use of Antiviral Monotherapy for Bell’s Palsy (Inverse Measure) AAO14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of patients with cerumen impaction and a suggestive history of a non-intact tympanic membrane who receive just manual removal. AAO15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Audiometric Evaluation for Older Adults with Hearing Loss AAO16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Advanced Diagnostic Imaging of Bilateral Presbycusis or Symmetric Sensorineural Hearing Loss-Avoidance of Inappropriate Use AAO17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of visits with patients with hearing aids where otoscopy is routinely performed AAO18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Shared Decision Making for Treatment Options for Bilateral Presbycusis or Symmetric Sensorineural Hearing Loss AAO19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Otitis Media with Effusion: Hearing Testing AAO20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Audiometry for Chronic Otitis Media with Effusion in Children AAO21 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of patients with allergic rhinitis who do not receive sinonasal imaging for allergic rhinitis AAO22 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of patients with allergic rhinitis who are offered intranasal corticosteroids or oral antihistamines AAO23 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of patients with allergic rhinitis who do not receive leukotriene inhibitors AAO24 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of patients with allergic rhinitis who do not receive IgG-based immunoglobulin testing AAO25 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Otitis Media with Effusion: Diagnostic Evaluation - Assessment of Tympanic Membrane Mobility AAO26 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Otitis Media with Effusion: Resolution of Otitis Media with Effusion in Children AAO27 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Otitis Media with Effusion: Resolution of Otitis Media with Effusion in Adults AAO28 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use AAO8 QCDR measure Process Y 0.8 99.8 -- -- -- -- -- -- -- 100 Yes No
All Patients Who Die an Expected Death with an ICD that Has Been Deactivated ABFM1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patients Admitted to ICU who Have Care Preferences Documented ABFM2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patients Treated with an Opioid Who Are Given a Bowel Regimen ABFM3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Palliative Care – Spiritual Assessment ABFM4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Palliative Care—Treatment Preferences ABFM5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Palliative Care Timely Dyspnea Screening & Treatment ABFM6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Pain Brought Under Control within the first three visits ABFM7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure ABFM8 QCDR measure Structure N -- -- -- -- -- -- -- -- -- -- -- No
Intra-operative anesthesia safety ABG1 QCDR measure Outcome Y 0.2 100 99.98 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Planned use of difficult airway equipment ABG16 QCDR measure Process Y 25.7 71.6 56.01 - 61.14 61.15 - 72.26 72.27 - 77.96 77.97 - 82.24 82.25 - 89.40 89.41 - 94.18 94.19 - 99.83 >= 99.84 No No
Pre-operative OSA assessment ABG21 QCDR measure Process Y 34.1 67.1 29.34 - 48.18 48.19 - 62.50 62.51 - 84.86 84.87 - 90.41 90.42 - 95.13 95.14 - 99.76 99.77 - 99.99 100 No No
Pre-Operative Screening for GERD ABG28 QCDR measure Process Y 32.2 58.2 32.09 - 44.87 44.88 - 50.15 50.16 - 52.83 52.84 - 58.27 58.28 - 87.25 87.26 - 98.87 98.88 - 99.99 100 No No
Pre-Operative Screening for Glaucoma ABG29 QCDR measure Process Y 32.3 77.8 44.29 - 67.22 67.23 - 95.02 95.03 - 99.50 99.51 - 99.99 -- -- -- 100 Yes No
Pre-Operative Screening for PONV Risk ABG30 QCDR measure Process Y 24.9 86 76.64 - 93.46 93.47 - 97.59 97.60 - 99.05 99.06 - 99.66 99.67 - 99.99 -- -- 100 Yes No
Pre-Operative Screening for Excessive Alcohol and Recreational Drug Use ABG31 QCDR measure Process Y 25.5 87.5 89.72 - 98.87 98.88 - 99.66 99.67 - 99.97 99.98 - 99.99 -- -- -- 100 Yes No
Pain Related Quality of Life Interference ABG32 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Lower Body Functional Impairment (LBI) ABG33 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Mood Assessment Screening and treatment ABG34 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Preoperative Assessment of Frailty ABG35 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Corneal Abrasion ABG36 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Immediate Adult Post-Operative Pain Management ABG7 QCDR measure Outcome Y 3.5 98.4 97.85 - 98.62 98.63 - 99.28 99.29 - 99.82 99.83 - 99.99 -- -- -- 100 Yes No
ACCPin3 Heart Failure: Patient Self Care Education ACCPin3 QCDR measure Process Y 0 100 -- -- -- -- -- -- -- 100 Yes No
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older ACEP19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years ACEP20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding ACEP21 QCDR measure Process Y 17.5 15.5 24.61 - 19.33 19.32 - 15.93 15.92 - 9.06 9.05 - 5.75 5.74 - 3.78 3.77 - 0.01 -- 0 No No
Appropriate Emergency Department Utilization of CT for Pulmonary Embolism ACEP22 QCDR measure Process Y 18.8 25.3 8.00 - 14.99 15.00 - 18.95 18.96 - 22.72 22.73 - 26.55 26.56 - 29.46 29.47 - 36.66 36.67 - 50.58 >= 50.59 No No
Pregnancy Test for Female Abdominal Pain Patients ACEP24 QCDR measure Process Y 18.5 65.6 55.27 - 60.22 60.23 - 64.28 64.29 - 68.37 68.38 - 73.24 73.25 - 77.93 77.94 - 80.55 80.56 - 84.76 >= 84.77 No No
Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD ACEP25 QCDR measure Process Y 14.5 73.6 63.89 - 67.52 67.53 - 71.87 71.88 - 74.99 75.00 - 78.78 78.79 - 81.81 81.82 - 85.70 85.71 - 89.99 >= 90.00 No No
Sepsis Management: Septic Shock: Repeat Lactate Level Measurement ACEP29 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Sepsis Management: Septic Shock: Lactate Clearance Rate of >=10% ACEP30 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Foley Catheter Use in the Emergency Department ACEP31 QCDR measure Process Y 21.9 63 43.04 - 51.99 52.00 - 59.08 59.09 - 63.36 63.37 - 69.04 69.05 - 73.07 73.08 - 88.09 88.10 - 91.66 >= 91.67 No No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients ACEP32 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +) ACEP33 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999) ACEP35 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999) ACEP36 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999) ACEP37 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less) ACEP38 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Ends ACEP39 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients ACEP40 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +) ACEP41 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999) ACEP43 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k-59,999) ACEP44 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999) ACEP45 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less) ACEP46 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding EDs ACEP47 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Sepsis Management: Septic Shock: Lactate Level Management, Antibiotics Ordered, and Fluid Resuscitation ACEP48 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Screening for risk of opioid misuse/overuse ACMT1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Pregnancy test in women who receive a toxicologic consult ACMT2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
EKG assessment in acute overdoses ACMT3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate treatment for acetaminophen ingestions ACMT4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Assessment of suspected ethylene glycol or methanol exposures ACMT5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Repeat assessment of salicylate concentrations in overdose patients ACMT6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
High Risk Pneumococcal Vaccination ACPGR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination ACPGR2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and LVEF <40% on ACEI or ARB and Beta-blocker Therapy ACPGR3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
COPD Exacerbation Requiring Hospital Admission: Palliative Care Evaluation ACQR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
COPD Exacerbation: % of patients discharged from inpatient status on Long Acting Beta Agonist (LABA) bronchodilator ACQR2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
COPD: Steroids for no more than 5 days in COPD Exacerbation ACQR3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CHF Exacerbation Requiring Hospital Admission: Palliative Care Evaluation ACQR4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CHF: Document AHA/ACC staging of CHF (A-D) ACQR5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
POLST Utilization: POLST form reviewed or completed for any patients with limited code status (i.e. any status other than, "Attempt Resuscitation" if unresponsive, pulseless and not breathing; and "Full Treatment" if patient is pulseless and breathing) ACQR6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Sepsis Management: Septic Shock: Repeat Lactate Level Measurement within 6 hours ACQR7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Stroke/TIA: % of patients discharged on antithrombotic therapy ACQR8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Gout: Serum Urate Target ACR7 QCDR measure Intermediate Outcome Y 20.2 39.2 21.19 - 28.09 28.10 - 34.77 34.78 - 38.16 38.17 - 41.88 41.89 - 46.53 46.54 - 58.87 58.88 - 67.14 >= 67.15 No No
CT Colonography True Positive Rate ACRad1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Report Turnaround Time: Radiography (modified) ACRad15 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Report Turnaround Time: Ultrasound (Excluding Breast US) ACRad16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Report Turnaround Time: MRI ACRad17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Report Turnaround Time: CT ACRad18 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Report Turnaround Time: PET ACRad19 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Lung Cancer Screening Cancer Detection Rate (CDR) ACRad21 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Lung Cancer Screening Positive Predictive Value (PPV) ACRad22 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Report Turnaround Time: Mammography ACRad25 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate venous access for hemodialysis ACRad26 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement ACRad28 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement ACRad29 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Screening Mammography Cancer Detection Rate (CDR) ACRad3 QCDR measure Outcome Y 0.3 0.4 0.18 - 0.23 0.24 - 0.30 0.31 - 0.42 0.43 - 0.48 0.49 - 0.53 0.54 - 0.61 0.62 - 0.79 >= 0.80 No No
Rate of Inadequate Percutaneous Image-Guided Biopsy ACRad30 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. ACRad31 QCDR measure Outcome Y 0 100 -- -- -- -- -- -- -- 100 Yes No
Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level. ACRad32 QCDR measure Outcome Y 0 100 -- -- -- -- -- -- -- 100 Yes No
Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level ACRad33 QCDR measure Outcome Y 0 100 -- -- -- -- -- -- -- 100 Yes No
Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy Recommended) ACRad6 QCDR measure Outcome Y 8.6 27.3 20.00 - 21.61 21.62 - 23.07 23.08 - 26.08 26.09 - 29.89 29.90 - 31.99 32.00 - 35.58 35.59 - 37.15 >= 37.16 No No
Screening Mammography Node Negativity Rate ACRad7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Screening Mammography Minimal Cancer Rate ACRad8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Preoperative Composite ACS15 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Preventative Care and Screening: Tobacco Screening and Cessation Intervention ACS16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Preoperative Key Medications Review for Anticoagulation Medication ACS17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patient Frailty Evaluation ACS18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Intraoperative Composite ACS19 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Optimal Postoperative Communication Plan and Patient Care Coordination Composite ACS20 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Post-Acute Recovery Composite ACS21 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned Reoperation within the 30 Day Postoperative Period ACS22 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned Hospital Readmission within 30 Days of Principal Procedure ACS23 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Surgical Phases of Care Patient-Reported Outcome Composite Measure ACS24 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
Surgical Site Infection (SSI) ACS25 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Trauma Initial Assessment Composite ACSTrauma1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Mortality Rate Following Blunt Traumatic Injury to the Chest and/or Abdomen ACSTrauma2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Mortality Rate Following Penetrating Traumatic Injury to the Chest and/or Abdomen ACSTrauma3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Splenic Salvage Rate ACSTrauma4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Optimal Timing of Surgical or Procedural Intervention for Hemorrhage in Trauma ACSTrauma5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Optimal Ratio of Blood Product Transfusion ACSTrauma6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Timely Initiation of VTE Prophylaxis in Trauma Patients ACSTrauma7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Ventral Hernia Repair: Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period AHSQC1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned Hospital Readmission or Observation Visit within the 30 Day Postoperative Period AHSQC2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period AHSQC6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Ventral Hernia Repair: Biologic Mesh Prosthesis Use in Low Risk Patients AHSQC8 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
Ventral Hernia Repair: Pain and Functional Status Assessment AHSQC9 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Hip Arthroplasty: Postoperative Complications within 90 Days Following the Procedure AJRR1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy AJRR3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk Evaluation AJRR4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Comprehensive Diabetic Foot Examination APMA1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure AQI18 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Coronary Artery Bypass Graft (CABG): Stroke – Inverse Measure AQI41 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure – Inverse Measure AQI42 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient-Reported Experience with Anesthesia AQI48 QCDR measure Patient Reported Outcome Y 29.9 78.8 55.23 - 60.02 60.03 - 94.51 94.52 - 99.08 99.09 - 99.98 99.99 - 99.99 -- -- 100 Yes No
Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite AQI49 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Application of Lung-Protective Ventilation during General Anesthesia AQI50 QCDR measure Intermediate Outcome Y 5.9 98.4 99.14 - 99.45 99.46 - 99.82 99.83 - 99.99 -- -- -- -- 100 Yes No
Assessment of Patients for Obstructive Sleep Apnea AQI51 QCDR measure Process Y 31.1 83.5 79.31 - 92.61 92.62 - 96.39 96.40 - 99.34 99.35 - 99.79 99.80 - 99.94 99.95 - 99.99 -- 100 Yes No
Documentation of Anticoagulant and Antiplatelet Medications when Performing Neuraxial Anesthesia/Analgesia or Interventional Pain Procedures AQI53 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Use of Pencil-Point Needle for Spinal Anesthesia AQI54 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients AQI55 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA) AQI56 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Safe Opioid Prescribing Practices AQI57 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Infection Control Practices for Open Interventional Pain Procedures AQI58 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Multimodal Pain Management AQI59 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
New Corneal Injury Not Diagnosed Prior to Discharge AQI60 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Benign Prostate Hyperplasia: IPSS improvement after diagnosis AQUA12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Stress Urinary Incontinence (SUI): Revision surgery within 12 months of incontinence procedure AQUA13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Stones: Repeat Shock Wave Lithotripsy (SWL) within 6 months of treatment AQUA14 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Stones: Urinalysis documented 30 days before surgical stone procedures AQUA15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease AQUA16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Non-Muscle Invasive Bladder Cancer: Initiation of BCG 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS AQUA17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Non-Muscle Invasive Bladder Cancer: Early surveillance cystoscopy within 4 months of initial diagnosis AQUA18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Diagnosis of Type of Azoospermia and Diagnostic Testing for Obstructive Azoospermia AQUA19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Genetic Testing of the Azoospermic Male AQUA20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Management of Obstructive Azoospermia AQUA21 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Bone imaging and soft tissue imaging at the time of diagnosis of metastatic CRPC AQUA22 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Blood work for patients receiving abiraterone AQUA23 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Testosterone and PSA levels checked for CRPC patients AQUA24 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Use of Prednisone for CRPC patients on abiraterone AQUA25 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Benign Prostate Hyperplasia Care: Benign Prostate Hyperplasia AQUA26 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Testing for Vasectomy Patients AQUA27 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Hypogonadism: Testosterone and hematocrit within 6 months of starting testosterone replacement AQUA28 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Patient Report of Urinary function after treatment AQUA29 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Cryptorchidism: Inappropriate use of scrotal/groin ultrasound on boys AQUA3 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Patient Report of Sexual function after treatment AQUA30 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Hospital admissions/complications within 30 days of TRUS Biopsy AQUA8 QCDR measure Outcome Y 3.5 3.2 5.13 - 4.23 4.22 - 3.22 3.21 - 2.64 2.63 - 1.02 1.01 - 0.70 0.69 - 0.01 -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Risk Standardized Mortality Rate within 30 days following Trauma Operation ARCO10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival ARCO11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
STK-01: Venous Thromboembolism (VTE) Prophylaxis ARCO12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
STK 02: Ischemic stroke patients management -  ARCO13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Diabetes: Nutritional, Weight Loss Counseling, Reduction of Sedentary Behavior ARCO15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Dyspnea or Heart Failure: Use of BNP or NT- pro BNP screening ARCO16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Heart Failure: Use of Aldosterone Antagonists and Diuretics for Symptom Control ARCO17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Heart Failure: Counseling on Self-care, Including Monitoring Blood Pressure, Weight, Sodium Intake, and Physical Activity ARCO18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Promoting self-care for prevention and management of chronic conditions ARCO19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percentage of patients using self-monitoring with mobile technology or eHealth solutions to manage their diabetes, hypertension, sodium intake, nutritional status, physical activity, tobacco use, alcohol use, and sedentary behaviors ARCO20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Antipsychotic Use in Persons with Dementia ARCO3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Surgeon assessment for hereditary cause of breast cancer ASBS1 QCDR measure Process Y 2.2 99.3 99.16 - 99.99 -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Management of the axilla in breast cancer patients undergoing breast conserving surgery with a positive sentinel node biopsy ASBS10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Return to the operating room for re-excision of previous microscopically negative margins in invasive breast cancer patients undergoing breast conserving therapy ASBS12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Sentinel Node Biopsy for Patients with Ductal Carcinoma in Situ Alone ASBS13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Recommendation of Neoadjuvant Chemotherapy for Her2Neu positive invasive breast cancers that are >2.0cm in size and/or have needle biopsy proven axillary metastases. ASBS14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned 30 day re-operation after mastectomy ASBS7 QCDR measure Outcome Y 2.4 98.6 98.15 - 98.46 98.47 - 99.99 -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients ASNC1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol ASNC19 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) ASNC2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT-MPI studies performed without the use of thallium ASNC20 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
SPECT-MPI study appropriate imaging protocol selection for morbidly obese patients ASNC21 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT and PET MPI studies reporting Left Ventricular Ejection Fraction ASNC22 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT-MPI study clinical utilization of Attenuation Correction image acquisition ASNC23 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT-MPI study utilization of exercise as a stressor ASNC24 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT-MPI study adequate exercise testing performed ASNC25 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT and PET MPI studies meeting appropriate use criteria ASNC26 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SPECT and PET MPI studies not Equivocal ASNC27 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Effective dose less than or equal to 9 millisieverts as per ASNC guideline recommendations ASNC28 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
SPECT and PET MPI study documentation of stress perfusion defects ASNC29 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients ASNC3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Transthoracic Echo (TTE) studies meeting appropriate use criteria ASNC30 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Transthoracic Echo (TTE) studies reporting pulmonary artery pressures, 100% views, contrast use ASNC31 QCDR measure Efficiency N -- -- -- -- -- -- -- -- -- -- -- No
Avoiding myocardial Injury ASPIRE18 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Avoiding acute kidney injury ASPIRE19 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker ASPIRE2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Application of Lung-Protective Ventilation during General Anesthesia ASPIRE6 QCDR measure Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient Satisfaction with Information Provided during Breast Reconstruction ASPS10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Operative Time for Autologous Breast Reconstruction ASPS11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned hospital admission after panniculectomy ASPS12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Wound disruption rate after primary panniculectomy in patients with BMI > or = to 35 ASPS13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Wound disruption rate after primary panniculectomy in patients with BMI < 35 ASPS14 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Seroma rate after primary panniculectomy ASPS15 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Breast Reconstruction: Return to OR ASPS5 QCDR measure Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Breast Reconstruction: Flap Loss ASPS6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Rate of Blood Transfusion for Patients Undergoing Autologous Breast Reconstruction ASPS7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Coordination of Care for Patients Undergoing Breast Reconstruction ASPS8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Length of Stay Following Autologous Breast Reconstruction ASPS9 QCDR measure Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair AUGS1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Documentation of offering a preoperative pessary for Pelvic Organ Prolapse AUGS10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Documentation that a trial of conservative management was offered prior to use of procedure based therapy for urgency urinary incontinence AUGS11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Preoperative assessment of sexual function prior to pelvic organ prolapse repair AUGS3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Performing an intraoperative rectal examination at the time of prolapse repair AUGS4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse AUGS5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Route of Hysterectomy AUGS6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Documentation that conservative management was offered prior to fecal incontinence surgery or procedures AUGS7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Documentation of weight loss counseling prior to surgery for stress urinary incontinence procedures for obese women AUGS8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Over-utilization of synthetic mesh in the posterior compartment AUGS9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Comprehensive Assessment of Safety BIVARUS27 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Experience and Care Coordination BIVARUS28 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Care Team Communication BIVARUS32 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Procedure Readiness and Care BIVARUS33 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
Turn-Around Time (TAT) - Standard biopsies CAP1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cancer Protocol Elements for Carcinoma and Carcinosarcoma of the Endometrium CAP2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin CAP3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cancer Protocol Elements for Carcinoma of the Intrahepatic Bile Ducts Completed CAP4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cancer Protocol Elements for Hepatocellular Carcinoma Completed CAP5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cancer Protocol Elements for Carcinoma of the Pancreas Completed CAP6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Helicobacter pylori documentation rate CAP7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Turn-Around Time (TAT) - Lactate CAP8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Turn-Around Time (TAT) - Troponin CAP9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
1-Year Patient-Reported Pain and Function Improvement after Total Knee Arthroplasty CCOME1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
1-Year Patient-Reported Pain and Function Improvement after Total Hip Arthroplasty CCOME2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
1-Year Patient-Reported Pain and Function Improvement after Total Shoulder Arthroplasty CCOME3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
1-Year Patient-Reported Pain and Function Improvement after ACLR Surgery CCOME4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy CCOME5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
1-Year Patient-Reported Pain and Function Improvement after APM Surgery CCOME6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adequate Off-loading of Diabetic Foot Ulcer at each visit CDR1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Diabetic Foot Ulcer (DFU) Healing or Closure CDR2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Plan of Care Creation for Diabetic Foot Ulcer (DFU) Patients not Achieving 30% Closure at 4 Weeks AND Plan of Care Creation for Venous Leg Ulcer (VLU) Patients not Achieving 30% Closure at 4 Weeks CDR3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Adequate Compression at each visit for Patients with VLUs CDR5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Venous Leg Ulcer (VLU) outcome measure: Healing or Closure CDR6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcers CDR8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Use of Cellular and/or Tissue Based Product (CTP) in diabetic foot ulcers (DFUs) or venous leg ulcer (VLUs) among patients 18 years or older CDR9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Post operative hypocalcemia after thyroidectomy surgery CESQIP1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Related readmission for thyroid or parathyroid related problems CESQIP2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Pre operative ultrasound exam of patients with thyroid cancer CESQIP3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Persistent hypercalcemia CESQIP4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Related readmission for adrenal related problems CESQIP5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Vocal cord dysfunction following thyroidectomy CESQIP7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Hematoma requiring evacuation following thyroidectomy CESQIP8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Back Pain: Use of EMG & CNS CLLC1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Morton's Neuroma - Avoidance of Alcohol Injections CLLC2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cancer Patients - Survivorship Care Plan CLLC3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Foot Bone Infection Diagnosis Without MRI CLLC4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Improved Global Physical Health Outcome Assessment for Shoulder Replacement CODE1 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Global Physical Health Outcome Assessment for Shoulder Arthroscopy CODE10 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Functional Outcome Assessment for Knee Arthroscopy CODE11 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Functional Outcome Assessment for Hip Arthroscopy CODE12 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Functional Outcome Assessment for ACL Repair CODE2 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Functional Outcome Assessment for Foot/Ankle Repair CODE3 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Global Physical Health Outcome Assessment for Spine Surgery CODE5 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Functional Outcome Assessment for Hip Replacement CODE6 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Functional Outcome Assessment for Knee Replacement CODE7 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Global Physical Health Outcome Assessment for Cervical Surgery CODE8 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved Global Physical Health Outcome Assessment for Hand/Wrist/Elbow Repair CODE9 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys) CUHSM3 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CAHPS Health Plan Survey v 4.0 - Adult questionnaire CUHSM4 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder CUHSM6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications CUHSM8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOneEGFR CURE1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOneNSCLCBRAFTTP CURE10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CureOneMelBRAFTTP CURE11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CureOneALK CURE2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOneROS1 CURE3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOneNSCLCBRAF CURE4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOnePDL1 CURE5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOneMelBRAF CURE6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CureOneEGFRTTP CURE7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CureOneALKTTP CURE8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CureOneROS1TTP CURE9 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Three Day All Cause Return ED Visit Rate ECPR11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Door to Diagnostic Evaluation by a Provider – Emergency Department (ED) Patients ECPR2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients ECPR5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients ECPR6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Avoid Head CT for Patients with Uncomplicated Syncope ECPR39 QCDR measure Process Y 8.9 87.6 83.33 - 84.77 84.78 - 87.17 87.18 - 88.44 88.45 - 90.90 90.91 - 92.67 92.68 - 94.43 94.44 - 96.98 >= 96.99 No No
Initiation of the Initial Sepsis Bundle ECPR40 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure ECPR41 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Restrictive Use of Blood Transfusions ECPR42 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Avoidance of Creatine Kinase-MB (CK-MB) Testing for Non-traumatic Chest Pain ECPR45 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Avoidance of Opiate Prescriptions for Low Back Pain or Migraines ECPR46 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Avoidance of Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain ECPR47 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions ECPR48 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Avoidance of Tramadol or Codeine for Children ECPR49 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients ECPR50 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Preoperative Frailty Assessment EPREOP28 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Preoperative Assessment for Opioid Dependence Risk EPREOP29 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Short-term Pain Management/Maximum Pain Score EPREOP4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Review of Functional Status Assessment for Patients with Osteoarthritis FORCE20 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Review of Pain Status Assessment for Patients with Osteoarthritis FORCE21 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improvement in Pain after Knee Replacement FORCE22 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improvement in Pain after Hip Replacement FORCE23 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate management of anticoagulation in the peri-procedural period rate – EGD GIQIC10 QCDR measure Process Y 31 65.2 31.25 - 52.34 52.35 - 61.53 61.54 - 66.77 66.78 - 81.35 81.36 - 90.90 90.91 - 98.90 98.91 - 99.99 100 No No
Appropriate indication for colonoscopy GIQIC12 QCDR measure Process Y 10.5 89 83.71 - 87.91 87.92 - 90.17 90.18 - 91.82 91.83 - 93.51 93.52 - 95.00 95.01 - 96.57 96.58 - 98.14 >= 98.15 No No
Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients GIQIC15 QCDR measure Process Y 17.4 75.7 61.11 - 71.42 71.43 - 76.09 76.10 - 79.19 79.20 - 83.66 83.67 - 87.12 87.13 - 90.23 90.24 - 93.74 >= 93.75 No No
Appropriate follow-up interval of 5 years for colonoscopies with findings of sessile serrated polyps < 10 mm without dysplasia GIQIC17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm GIQIC18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate indication for esophagogastroduodenoscopy (EGD) GIQIC19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate follow-up interval of 10 years for colonoscopies with only hyperplastic polyp findings GIQIC20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
HAdv1 - Use of high risk sleep medications in the elderly HAdv1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
HAdv2 - Atrial Fibrillation Prevention and Treatment – Lifestyle and Disease Factor Assessment HAdv2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Mean Length of Stay for Inpatients – Pneumonia HCPR3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Mean Length of Stay for Inpatients – CHF HCPR4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Mean Length of Stay for Inpatients – COPD HCPR5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Stroke Venous Thromboembolism (VTE) Prophylaxis HCPR13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Venous Thromboembolism (VTE) Prophylaxis HCPR14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Physician’s Orders for Life-Sustaining Treatment (POLST) Form HCPR16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Pressure Ulcers - Risk Assessment and Plan of Care HCPR17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Unintentional Weight Loss - Risk Assessment and Plan of Care HCPR18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
30 Day All-Cause Readmission Rate for Discharged Inpatients HCPR19 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Clostridium Difficile - Risk Assessment and Plan of Care HCPR20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Use of Telemetry for Admission or Observation Placement HCPR21 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Care Transfer of Care - Use of Verbal Checklist or Protocol HCPR22 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Exclusive Breast Milk Feeding HEF1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Surgical Reconstruction for Anterior Cruciate Ligament (ACL) Injury HF2 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder HF3 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Shoulder Arthroscopy: Measure of Change in a Validated Shoulder Patient Reported Outcome Following Shoulder Arthroscopy HF4 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Shoulder Arthroplasty: Change in a Validated Shoulder Patient Reported Outcome Measure Following Shoulder Arthroplasty HF5 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Patient Reported Outcome Measure Following Knee Arthroscopy for Meniscal Repair HF6 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair HF7 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
ACE/ARB use HM1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
A1C treatment HM2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
A1C in good control HM3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Hypogonadism: Serum T, CBC, PSA, IPSS within 6 months of Rx IQSS1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Newly diagnosed with document T, PSA, Gleason and Prostate Cancer: Initial Eval. Document T, PSA, Gleason IQSS2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Treatment Options Counseling IQSS3 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
BPH: Anticholinergics IQSS4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Counseling SUI IQSS5 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
Endothelial Keratoplasty: Post-operative improvement in best corrected visual acuity to 20/40 or greater IRIS1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Exudative Age-Related Macular Degeneration - Loss of Visual Acuity IRIS10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Nonexudative Age-Related Macular Degeneration - Loss of Visual Acuity IRIS11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Diabetic Macular Edema - Loss of Visual Acuity IRIS13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Acute Anterior Uveitis - Post-treatment visual acuity IRIS16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Acute Anterior Uveitis - Post-treatment Grade 0 anterior chamber cells IRIS17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Chronic Anterior Uveitis - Post-treatment visual acuity IRIS18 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Glaucoma - Intraocular Pressure (IOP) Reduction IRIS2 QCDR measure Outcome Y 9.6 94.5 86.96 - 97.36 97.37 - 98.99 99.00 - 99.99 -- -- -- -- 100 Yes No
Idiopathic Intracranial Hypertension: No worsening or improvement of mean deviation IRIS20 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Ocular Myasthenia Gravis: Improvement of ocular deviation or absence of diplopia or functional improvement IRIS21 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Giant Cell Arteritis: Absence of fellow eye involvement after treatment IRIS22 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Refractive Surgery: Postoperative Improvement in Uncorrected Visual Acuity of 20/20 or better IRIS23 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Refractive Surgery: Postoperative correction within + 0.5 Diopter of the Intended Correction IRIS24 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Adenoviral Conjunctivitis: Avoidance of Antibiotics IRIS25 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
Intravitreal Injections: Avoidance of Routine Antibiotic Use IRIS26 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
Adverse Events After Cataract Surgery IRIS27 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Regaining Vision After Cataract Surgery IRIS28 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Improved visual acuity after epiretinal membrane treatment within 90 days IRIS29 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Glaucoma - Visual Field Progression IRIS3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Return to OR within 90 days after epiretinal membrane surgical treatment IRIS30 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Avoidance of Genetic Testing for Age-related Macular Degeneration IRIS31 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT. IRIS32 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Return to OR within 90 days after macular hole surgery IRIS33 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Age-Related Macular Degeneration: Disease Progression IRIS34 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty IRIS4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Surgery for Acquired Involutional Ptosis - Patients with an Improvement of Marginal Reflex Distance IRIS5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Acquired Involutional Entropion - Normalized Lid Position After Surgical Repair IRIS6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Amblyopia - Interocular Visual Acuity IRIS7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Surgical Esotropia - Postoperative Alignment IRIS8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Diabetic Retinopathy - Documentation of the Presence or Absence of Macular Edema and the Level of Severity of Retinopathy IRIS9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Functional Improvement in hip, leg or ankle rehabilitation in patients with lower extremity injury measured via the validated Lower Extremity Function Scale (LEFS) score. IROMS1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Improvement in low back rehabilitation of non-surgical patients with low pack pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ). IROMS10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score. IROMS2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Improvement in arm, shoulder, and hand rehabilitation in surgical patients with musculotendinous injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score. IROMS8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Improvement in neck pain/injury patients rehabilitation measured via the validated Neck Disability Index (NDI). IROMS9 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 1: Procedures with statin and antiplatelet agents prescribed at discharge M2S1 QCDR measure Process Y 12.3 79.4 70.25 - 77.54 77.55 - 80.46 80.47 - 81.25 81.26 - 81.61 81.62 - 84.56 84.57 - 89.82 89.83 - 92.81 >= 92.82 No No
M2S 10: Survival at least 9 months after elective repair of small thoracic aortic aneurysms M2S10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 11: Imaging-based maximum aortic diameter assessed at least 9 months following Endovascular AAA Repair procedures M2S11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
M2S 12: Survival at least 9 months after elective repair Endovascular AAA Repair of small abdominal aortic aneurysms M2S12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 13: Survival at least 9 months after elective Open AAA repair of small abdominal aortic aneurysms M2S13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Absence of unplanned reoperation after closed lower extremity major amputation M2S16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 17: Absence of serious technical complications during peripheral arterial intervention M2S17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 19: Proper patient selection for perforator vein ablation M2S19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
M2S 2: Amputation-free survival assessed at least 9 months following Infra-Inguinal Bypass for intermittent claudication M2S2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 5: Amputation-free survival at assessed at least 9 months following Peripheral Vascular Intervention for intermittent claudication M2S5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 7: Ipsilateral stroke-free survival at assessed at least 9 months following Carotid Artery Stenting for asymptomatic procedures M2S7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 8: Ipsilateral stroke-free survival assessed at least 9 months following isolated Carotid Endarterectomy for asymptomatic procedures M2S8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
M2S 9: Imaging-based maximum aortic diameter assessed at least 9 months following Thoracic and Complex EVAR procedures M2S9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Case Delay MA1 QCDR measure Efficiency N -- -- -- -- -- -- -- -- -- -- -- No
Corneal Abrasion MA3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Anxiety Utilization of the GAD-7 Tool MBHR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Anxiety Response at 6-months MBHR2 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk standardized rate of patients who experienced a postoperative escalation in care event following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation MBSAQIP10 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Risk standardized rate of patients who experienced a pulmonary complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy MBSAQIP11 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Risk standardized rate of patients who experienced a postoperative complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation MBSAQIP12 QCDR measure Composite N -- -- -- -- -- -- -- -- -- -- -- No
Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation MBSAQIP7 QCDR measure Outcome Y 1.4 1.2 2.13 - 1.85 1.84 - 1.29 1.28 - 0.40 0.39 - 0.01 -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Risk standardized rate of patients who experienced an extended length of stay (> 3 days) following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation MBSAQIP8 QCDR measure Outcome Y 1.4 0.5 -- -- -- -- -- -- -- 0 Yes Yes - see "Scoring Examples" tab of spreadsheet
Use of a “PEG Test” to Manage Patients Receiving Opioids MEDNAX52 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
MEX1: Heel Pain Treatment Outcomes for Adults MEX1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Vascular Testing Outcome Measure Supervised Programs MEX10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-19: Non-Invasive Vascular Testing in Patients with Abnormal CVI Screening That Completed Hyperbaric Oxygen Therapy MEX11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Peripheral Vascular Assessment % of Diabetic Patients 50+ MEX12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-22: Patients with Lower Limb Ulceration with a Previously Abnormal Vascular Study Receiving Negative Pressure Wound Therapy MEX13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX2: Heel Pain Treatment Outcomes for Pediatric Patients MEX2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX3: Identification of Flat Foot in Pediatric Patients MEX3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-2: Bunion Outcome - Adult and Adolescent MEX4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-3: Hammer Toe Outcome MEX5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-11: Peripheral Vascular Assessment - Patients 70+ MEX6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-6: Foot Wound Outcome MEX7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-20: Non-Invasive Vascular Testing Follow-up in Patients After Revascularization MEX8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MEX2018-16: Non-Invasive Vascular Testing in Patients Diagnosed with Intermittent Claudication Who Use Cilostazol or Pentoxifylline MEX9 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Plan All Cause Readmissions MHAN3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
General Health Postoperative Improvement MICS1 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Surgery Specific Postoperative Improvement in Pain Levels MICS2 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Surgery Specific Postoperative Improvement in Function Levels MICS3 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Perioperative Pain Plan MIRAMED16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of witnessed gastric aspiration MIRAMED17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned Conversion to General Anesthesia from Regional or MAC for all scheduled cases MIRAMED18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Onset atrial fibrillation or dysrthymia requiring unanticipated therapy MIRAMED19 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Perioperative cognitive function test in elderly MIRAMED20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication MNCM5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Diabetes A1c Control (<8.0) MNCM6 QCDR measure Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment MOA1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities MOA12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders MOA13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety MOA14 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Weight loss in pain patients with BMI > = 30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control MOA15 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology MOA2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur MOA7 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Pre-surgical screening for depression MSSIC1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients achieving MCID for pain-related disability (ODI/NDI) MSSIC10 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent Satisfied with Result MSSIC11 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted rate of hospital readmission MSSIC12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted rate of surgical site infection MSSIC13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted rate of urinary retention MSSIC14 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients achieving MCID for myelopathy MSSIC16 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent same-day ambulation MSSIC6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of use of Pre-op skin preparation/wash MSSIC7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients achieving MCID for back or neck pain MSSIC8 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients achieving MCID for leg or arm pain MSSIC9 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Biopsy Antibiotic Compliance MUSIC1 QCDR measure Process Y 0.4 99.8 -- -- -- -- -- -- -- 100 Yes Yes - see "Scoring Examples" tab of spreadsheet
Prostate Cancer: Confirmation Testing in low risk AS eligible patients MUSIC10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months MUSIC11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients MUSIC3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients MUSIC4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Cancer: Radical Prostatectomy Cases LOS MUSIC5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Prostate Biopsy: Repeat Biopsy for Patients with Atypical Small Acinar Proliferation (ASAP) MUSIC9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Telephone Contact, Virtual, or In-person Visit Within 48 Hours of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients NHBPC10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Interdisciplinary Team Assessment for Home-Based Primary care and Palliative Care Patients NHBPC13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cognitive Assessment for Home-Based Primary Care and Palliative Care Patients NHBPC14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
A Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients (Multiperformance Measure) NHBPC15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Outcome for Home-Based Primary Care and Palliative Care Practices NHBPC16 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Screening for Depression and Follow-up Plan in Home-Based Primary Care and Palliative Care Patients NHBPC17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Alcohol Problem Use Assessment for Home-Based Primary Care and Palliative Care Patients NHBPC2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Screen for Risk of Future Fall for Home-Based Primary Care and Palliative Care Patients NHBPC6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure) NHBPC7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Referral to Hospice for Appropriate Home-Based Primary Care and Palliative Care Patients NHBPC9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
NHCR4: Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation NHCR4 QCDR measure Process Y 27.4 38.5 12.50 - 19.37 19.38 - 23.66 23.67 - 33.98 33.99 - 40.33 40.34 - 49.38 49.39 - 68.20 68.21 - 80.29 >= 80.30 No No
NHCR5: Repeat colonoscopy recommended due to piecemeal resection NHCR5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate indication for colonoscopy NHCR9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
COMMUNICATING CONCURRENT OPIOID AND BENZODIAZEPINE PRESCRIBING TO OTHER PRESCRIBERS NIPM10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
PATIENT COUNSELING REGARDING RISKS OF CO-PRESCRIBED OPIOIDS AND BENZODIAZEPINES NIPM11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
FUNCTIONAL STATUS ASSESSMENT FOR SPINAL CORD STIMULATOR IMPLANTATION NIPM12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
FUNCTIONAL STATUS ASSESSMENT FOR LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION NIPM13 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
FUNCTIONAL STATUS ASSESSMENT FOR CERVICAL MEDIAL BRANCH RADIOFREQUENCY ABLATION NIPM14 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
REDUCTION IN PATIENT REPORTED PAIN FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION FOR FAILED BACK SURGERY SYNDROME NIPM15 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
REDUCTION IN PATIENT REPORTED PAIN FOLLOWING LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION NIPM16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
REDUCTION IN PATIENT REPORTED PAIN FOLLOWING CERVICAL/THORACIC MEDIAL BRANCH RADIOFREQUENCY ABLATION NIPM17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
APPROPRIATE PATIENT SELECTION FOR DIAGNOSTIC FACET JOINT PROCEDURES NIPM4 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE CERVICAL AND THORACIC SPINE NIPM8 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC CERVICAL AND THORACIC SPINAL PAIN NIPM9 QCDR measure Cost/Resource Use N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Pulmonary Embolism NJIISMD1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Ruptured Ectopic Pregnancy NJIISMD10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: New Deep Venous Thrombosis (DVT) NJIISMD11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Ectopic Pregnancy NJIISMD12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Result Requiring Follow Up Protocol NJIISMD17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Cord Compression NJIISMD19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: ICH NJIISMD2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: CTA of GI bleed NJIISMD20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Positive bleeding scan NJIISMD21 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Acute Ocular injury NJIISMD22 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Aortic Dissection NJIISMD3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Occlusive Intracranial Stroke NJIISMD8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Placental abruption NJIISMD9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Substance Use Screening NNEPTN1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Transforming Clinical Practice Initiative Common Measure Name: Substance Use Screening and Intervention Composite NNEPTN2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Transforming Clinical Practice Initiative Common Measure Name: TCP01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team NNEPTN3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Median Time to Pain Management for Long Bone Fracture NOF12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older NOF13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Hip Fracture Mortality Rate (IQI 19) NOF6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Osteoporosis: percentage of patients, any age, with a diagnosis of osteoporosis who are either receiving both calcium & vitamin D intake, & exercise at least once within 12 months. NOF7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned Readmission Following Spine Procedure within the 30-Day Postoperative Period NPA11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Selection of Prophylactic Antibiotic Prior to Spine Procedure NPA12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Medicine Reconciliation Following Spine Related Procedure NPA14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Risk Assessment for Elective Spine Procedure NPA15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Depression and Anxiety Assessment Prior to Spine-Related Therapies NPA16 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Narcotic Pain Medicine Management Following Elective Spine Procedure NPA17 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Smoking Assessment and Cessation Coincident With Spine-Related Therapies NPA18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Body Mass Assessment and Follow-up Coincident With Spine-Related Therapies NPA19 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Unhealthy Alcohol Use Assessment Coincident With Spine Care NPA20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Spine/Extremity Pain Assessment NPA23 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Outcome Assessment for Spine Intervention NPA3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Quality-of-Life Assessment for Spine Intervention NPA4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient Satisfaction With Spine Care NPA5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Spine-Related Procedure Site Infection NPA6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Spine/Extremity Pain Assessment NPAGSC10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Outcome Assessment for Spine Intervention NPAGSC3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Quality-of-Life Assessment for Spine Intervention NPAGSC4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient Satisfaction with Spine Care NPAGSC5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Depression and Anxiety Assessment Prior to Spine-Related Therapies NPAGSC6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Narcotic Pain Medicine Management Prior to and Following Spine Therapy NPAGSC7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Complication Following Percutaneous Spine-Related Procedure NPAGSC8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-Day Post-procedure Period NPAGSC9 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI). NPQR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of amended pathology reports with a major discrepancy NPQR10 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of communicating results of an amended report with a major discrepancy to the responsible provider NPQR11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of cytopathology case review NPQR12 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of notification to clinical provider of a new diagnosis of malignancy NPQR13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Frozen section diagnosis within 20 minutes of receipt in lab (single block frozen section) NPQR14 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorder NPQR2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitis NPQR3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Time interval: critical value reporting for chemistry NPQR4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC) NPQR5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Time interval: critical value reporting for toxicology NPQR6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Time interval: critical value reporting for troponin NPQR7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of review of slides with high-grade squamous intraepithelial lesion (HSIL) with negative cervical biopsies NPQR8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Rate of follow up letter after high-grade squamous intraepithelial lesion (HSIL) pap test NPQR9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Post Stroke Outcome and Follow-Up OBERD22 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Health Related Quality of Life: Patient Defined Outcomes OBERD23 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Tracking Satisfaction Improvement with CG-CAHPS OBERD25 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Cervical Spine Functional Outcomes OBERD26 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Foot/Ankle Functional Outcomes OBERD27 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Hip Functional Outcomes OBERD28 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Knee Functional Outcomes OBERD29 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Lumbar Spine Functional Outcomes OBERD30 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Quality of Life-Mental Health Outcomes OBERD31 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Quality of Life - Physical Health Outcomes OBERD32 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient Acceptable Symptom State Outcomes OBERD33 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Upper Extremity Functional Outcomes OBERD34 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Emergent transfer from an outpatient, ambulatory surgical center, or office setting OEIS2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Antiplatelet Therapy OEIS3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Lipid-Lowering Medications for Patients with PAD OEIS4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention OEIS6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Goal Setting and Attainment for Cancer Survivors ONSQIR18 QCDR measure Patient Engagement Experience N -- -- -- -- -- -- -- -- -- -- -- No
Fatigue Improvement ONSQIR20 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Advance Care Planning in Stage 4 Disease PIMSH1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Utilization of GCSF in Metastatic Colon Cancer PIMSH2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0 or Stage IB-III hormone receptor negative breast cancer PIMSH3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted 30 day Readmission for Acute Myocardial Infarction Pinc1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted 30 day Readmission for Heart Failure Pinc2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted 30 day Readmission for Pneumonia Pinc3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction Pinc33 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure Pinc34 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia Pinc35 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted 30 day Inpatient Mortality for Acute Myocardial Infarction Pinc4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted 30 day Inpatient Mortality for Heart Failure Pinc5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risk-adjusted 30 day Inpatient Mortality for Pneumonia Pinc6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Annual Monitoring for Patients on Persistent Medications (MPM) PP1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Follow-Up After Hospitalization for Schizophrenia (7- and 30-day) PP2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
ADHD: Symptom Reduction in Follow up Period PP3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Risky Behavior Assessment or Counseling by Age 18 Years PP4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment; AND if there is no change or deterioration in symptoms, a revised care plan is documented following the 12 week monitoring phase PP5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Pharmacological Treatment of Dementia PP6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC) PP7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Chronic Kidney Disease (CKD): eGFR Monitoring PPRNET13 QCDR measure Process Y 14.6 71.4 62.50 - 64.85 64.86 - 70.58 70.59 - 73.32 73.33 - 76.04 76.05 - 80.18 80.19 - 84.23 84.24 - 89.05 >= 89.06 No No
Chronic Kidney Disease (CKD): Hemoglobin Monitoring PPRNET14 QCDR measure Process Y 12.4 82.7 72.62 - 77.21 77.22 - 82.85 82.86 - 87.29 87.30 - 89.86 89.87 - 90.53 90.54 - 93.09 93.10 - 94.58 >= 94.59 No No
Appropriate Treatment for Adults with Upper Respiratory Infection PPRNET24 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF), Hypertension (HTN), or Chronic Kidney Disease (CKD) PPRNET28 QCDR measure Process Y 7.1 84.4 80.00 - 81.80 81.81 - 82.91 82.92 - 84.83 84.84 - 85.94 85.95 - 86.76 86.77 - 91.40 91.41 - 93.07 >= 93.08 No No
Monitoring Serum Creatinine PPRNET29 QCDR measure Process Y 22.1 80.3 73.35 - 78.88 78.89 - 84.40 84.41 - 86.29 86.30 - 88.09 88.10 - 90.88 90.89 - 93.85 93.86 - 96.29 >= 96.30 No No
Screening for Type 2 Diabetes PPRNET31 QCDR measure Process Y 18.8 83.4 82.72 - 84.17 84.18 - 85.53 85.54 - 87.24 87.25 - 90.70 90.71 - 92.15 92.16 - 93.92 93.93 - 96.19 >= 96.20 No No
Screening for albuminuria in patients at risk for CKD (DM and/or HTN) PPRNET32 QCDR measure Process Y 26.8 46.9 18.26 - 26.78 26.79 - 47.26 47.27 - 56.41 56.42 - 61.65 61.66 - 66.11 66.12 - 72.25 72.26 - 75.06 >= 75.07 No No
Avoiding Use of CNS Depressants in Patients on Long-Term Opioids PPRNET33 QCDR measure Process Y 12 60.7 50.51 - 54.54 54.55 - 55.58 55.59 - 57.79 57.80 - 60.14 60.15 - 65.24 65.25 - 72.38 72.39 - 81.62 >= 81.63 No No
Zoster (Shingles) Vaccination PPRNET34 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Antiplatelet Medication for High Risk Patients PPRNET8 QCDR measure Process Y 18.2 47.4 27.68 - 36.18 36.19 - 41.59 41.60 - 47.90 47.91 - 50.61 50.62 - 59.08 59.09 - 67.67 67.68 - 74.60 >= 74.61 No No
Combination chemotherapy received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) to III ER/PR negative breast cancer QOPI11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
GCSF administered to patients who received chemotherapy for metastatic cancer (Lower Score -Better) QOPI15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Oncology: Treatment Summary Communication – Radiation Oncology QOPI21 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
External Beam Radiotherapy for Bone Metastases QOPI22 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (Lower Score - Better) QOPI5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Central Line Ultrasound Guidance Quantum31 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Case Cancellation on Day of Surgery Quantum41 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
CKD 3-5 Patients Seen at the Recommended Frequency Levels RCOIR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Upper Extremity Edema Improvement RCOIR10 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Optimal End Stage Renal Disease (ESRD) Starts RCOIR11 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test RCOIR3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
CKD 4-5 Patients with Transplant Referral RCOIR4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
ESRD Prevalence of Home Dialysis or Self-Care RCOIR5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Improved Access Site Bleeding RCOIR7 QCDR measure Outcome Y 21.2 54.1 37.04 - 40.21 40.22 - 44.52 44.53 - 59.99 60.00 - 63.63 63.64 - 66.66 66.67 - 69.22 69.23 - 74.99 >= 75.00 No No
Post Procedure Bleeding RCOIR8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy RPAQIR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Hospitalization Rate Following Procedures Performed under Procedure Sedation Analgesia RPAQIR11 QCDR measure Outcome Y 0.6 0.3 0.58 - 0.27 0.26 - 0.08 0.07 - 0.01 -- -- -- -- 0 Yes No
Arterial Complication Rate Following Arteriovenous Access Intervention RPAQIR12 QCDR measure Outcome Y 0.7 0.6 0.99 - 0.74 0.73 - 0.55 0.54 - 0.40 0.39 - 0.01 -- -- -- 0 Yes No
Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician RPAQIR13 QCDR measure Process Y 7 94.2 92.85 - 94.06 94.07 - 94.94 94.95 - 95.86 95.87 - 97.27 97.28 - 97.88 97.89 - 99.20 99.21 - 99.76 >= 99.77 Yes No
Arteriovenous Graft Thrombectomy Success Rate RPAQIR14 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Arteriovenous Fistulae Thrombectomy Success Rate RPAQIR15 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Peritoneal Dialysis Catheter Success Rate RPAQIR16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Peritoneal Dialysis Catheter Exit Site Infection Rate RPAQIR17 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Advance Directives Completed RPAQIR18 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Adequacy of Volume Management RPAQIR2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Arteriovenous Fistula Rate RPAQIR4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Transplant Referral RPAQIR5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Advance Care Planning (Pediatric Kidney Disease) RPAQIR9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Improvement in Quality of Life from Partial Foot, Prosthetics SCG05 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
SCG1 Evaluation of High Risk Pain Medications for MME SCG1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SCG2 Outcome Assessment for Patients Prescribed Ankle Orthosis for Ambulation and Functional Improvement SCG2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement SCG3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Prevention of Antibiotic or Herbal Supplement Impairment of Anesthesia SCG4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Outcome of High Risk Pain Medications Prescribed in Last 6 Months SCG6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Education of patients with inflammatory diseases regarding increased cardiovascular risk and the need for PCP evaluation SDPAD1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
HCV testing in Lichen Planus SDPAD2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Avoiding antibiotic use in rupture epidermal inclusion cyst SDPAD3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Appropriate Testing and Treatment of Nail tinea infection SDPAD4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Urgent Result: Breast Specimen Radiography SMD23 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Testicular Torsion SMD24 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Critical Result: Subdural hematoma SMD25 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
GI Radiography Result Notification •Critical Result: Bowel Obstruction •Critical Result: Sigmoid Volvulus SMD26 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Chest Imaging Result Notification: •Critical Result: Pneumothorax •Critical Result: Tension Pneumothorax •Follow Up Result: Suspicious Lung Nodule SMD27 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Musculoskeletal Radiology Result Notification: •Critical Result: Fracture C-Spine •Urgent Result: Osteomyelitis •Urgent Result: Meniscal Tear SMD28 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia SMX1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications SMX2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
SMX1004: Use of Multiple Concurrent Antipsychotics in Children and Adolescents SMX3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Medication Adherence for Diabetes Medication SMX5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Screening for Psychiatric or Behavioral Health Disorders SMX6 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Medication Adherence for Hypertension SMX7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Assessment and Intervention for Psychosocial Distress in Adults Receiving Cancer Treatment SMX8 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Mental Health Assessment for Patients with orthopedic conditions SMX9 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Repeated X-ray Imaging SPINEIQ3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Change in Functional Outcomes SPINEIQ5 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Change in Pain Intensity SPINEIQ6 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
MRI of the lumbar spine without prior conservative care SPINEIQ7 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Assessment and Management of Muscle Spasticity--Inpatient SQOD1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Management of Muscle Spasticity--Outpatient SQOD2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Post-Acute Brain Injury: Depression Screening and Follow-Up Plan of Care SQOD3 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Family Training—Inpatient Rehabilitation/Skilled Nursing Facility-Discharged to Home SQOD4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Functional Assessment to Determine Rehabilitation Needs SQOD5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prolonged Length of Stay Following Coronary Artery Bypass Grafting STS1 QCDR measure Outcome Y 4.8 5.4 8.26 - 6.97 6.96 - 5.89 5.88 - 4.63 4.62 - 3.50 3.49 - 2.74 2.73 - 1.84 1.83 - 0.01 0 No No
Operative Mortality for Lobectomy STS10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Lobectomy – Air Leak Greater than 5 Days STS11 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Lobectomy – Unplanned Return to OR STS12 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Recording Performance Status Prior to Lung Cancer Resection STS13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Prolonged Length of Stay for Coronary Artery Bypass Grafting (CABG) + Valve Replacement STS3 QCDR measure Outcome Y 9 10.3 21.21 - 14.30 14.29 - 9.10 9.09 - 7.46 7.45 - 5.01 5.00 - 4.77 4.76 - 2.71 2.70 - 0.01 0 Yes No
Prolonged Length of Stay following Valve Surgery STS5 QCDR measure Outcome Y 4.6 5.2 8.00 - 5.89 5.88 - 5.27 5.26 - 4.09 4.08 - 3.46 3.45 - 3.04 3.03 - 1.62 1.61 - 0.01 0 No No
Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery STS7 QCDR measure Patient Engagement Experience Y 39.5 47.2 2.73 - 6.55 6.56 - 22.77 22.78 - 51.51 51.52 - 69.99 70.00 - 83.77 83.78 - 92.47 92.48 - 99.16 >= 99.17 No No
Operative Mortality for Esophageal Resection STS8 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Recording Performance Status prior to Esophageal Cancer Resection STS9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients meeting MCID thresholds for back or neck pain SpineTRACK1 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients meeting MCID thresholds for leg or arm pain SpineTRACK2 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients meeting MCID thresholds for pain-related disability (ODI/NDI) SpineTRACK3 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients meeting SCB thresholds for back or neck pain SpineTRACK4 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients meeting SCB thresholds for leg or arm pain SpineTRACK5 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI) SpineTRACK6 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
UR002 - Ankylosing Spondylitis: Controlled Disease UREQA1 QCDR measure Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
UR003 - Ankylosing Spondylitis: Appropriate Pharmacologic Therapy UREQA2 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
UR008 - Controlled Gout for Patients on Urate-Lowering Pharmacologic Therapy UREQA3 QCDR measure Intermediate Outcome N -- -- -- -- -- -- -- -- -- -- -- No
UR007 - Folic or Folinic Acid Therapy for Patients Treated with Methotrexate UREQA4 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
UR006 - Regular Evaluation of Psoriatic Arthritis (PsA) UREQA5 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patient Vital Sign Assessment and Blood Glucose Check Prior to HBOT Treatment USWR13 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Major Amputation in Wagner 3, 4, or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT USWR16 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers USWR20 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers USWR22 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential USWR23 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Patient Reported Experience of Care: Wound Outcome USWR24 QCDR measure Patient Reported Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Advance Care planning: Electronic submission of new POLST/MOLST/POST/MOST ("orders for life-sustaining treatment" or "orders for scope of treatment") into an eRegistry powered by Medcordance VCMAHEMR1 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Diabetes Care All or None Outcome Measure: Optimal Control WCHQ10 QCDR measure Outcome N -- -- -- -- -- -- -- -- -- -- -- No
Screening For Osteoporosis WCHQ15 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Controlling High Blood Pressure: eGFR Test Annually WCHQ32 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No
Diabetes Care All or None Process Measure: Optimal Testing WCHQ9 QCDR measure Process N -- -- -- -- -- -- -- -- -- -- -- No

Scoring Examples

Table 3. Scoring examples using PY 2019 historical benchmark results.
Scoring Example 1. Measure 019, collected and reported as an eCQM
Dr. Clark submits data for Measure 019 (eCQM) that results in a performance rate of 80.21% and 7.4 achievement points.
Why?
This performance rate falls in Decile 7, which means a measure score of 7.0 - 7.9 points. The eCQM isn't topped out or capped at 7 points. See formula at right for partial points.
Scoring Example 2. Measure 065, collected and reported as a MIPS CQM
Dr. Clark submits data for Measure 065 (MIPS CQM) that results in a performance rate of 99.41% and 7.0 achievement points.
Why?
This performance rate falls in Decile 8, which would normally mean a measure score of 8.0 - 8.9 points. However, it's a topped out measure that is capped at 7 points (see Column Q on the MIPS Benchmark Results worksheet).
Scoring Example 3. Measure 225, collected and reported as a MIPS CQM
Dr. Clark submits data for Measure 2255 (MIPS CQM) that results in a performance rate of 99.99% and 3.0 achievement points.
Why?
Decile 10 is the only Decile with associated performance rates. Dr. Clark would have earned 10 points if the measure had a 100% performance rate. Any performance rate less than 100% is below Decile 3, and earns the 3 point floor for measures that can be scored against a benchmark.
Scoring Example 3. Measure 254, collected and reported as a Medicare Part B Claims Measure
Dr. Clark submits data for Measure 254 (Medicare Part B claims measure) that results in a performance rate of 99.99% and 3.0 achievement points at the point of submission.
Why?
There is no historical benchmark for Measure 254 (Medicare Part B claims collection type), which means it will earn 3.0 points (assuming case minimum and data completeness criteria are met) unless a performance period benchmark can be created for use in PY 2019.

Version History

Date of Change Version Notes
8/1/19 Revised column descriptions in the Column Descriptions worksheet (previously "Layout of Results") and corrected link for CMS Web Interface measure benchmarks Updated MIPS Benchmark Results worksheet: - Removed historical benchmark for Measure 144 (MIPS CQM) due to significant changes in the measure between the benchmarking period (PY 2017) and the performance period (PY 2019) - Column C now refers to collection type (not submission method) to align with the new terminology finalized in the CY 2019 rule - Removed the "Topped Out_PY2018" and "Topped Out_PY2019" columns (it wasn't clear that these only applied to measures capped at 7 points) Added a Scoring Examples worksheet
4/8/19 Corrected table description on the first row of the MIPS Benchmark Results tab; 2019 benchmarks are based on PY 2017 data (not 2016) and PY 2019 eligibility rules (not 2018)”
2/1/19 Corrected title for measure 419; Removed measures ACRad23 and ACRad5; Removed historic registry benchmarks for measure 419 and measure 343
1/30/19 Updated Layout of Results tab with link to Web Interface measure benchmark documentation