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How to Use This Tool

This tool has been created to help you get familiar with the different measures you can submit and prepare for the year. It's for planning purposes only and will not submit anything to CMS. To get the most out of the tool, follow the steps below:

  1. Explore (Search, browse, or filter) available measures
  2. Add measures you're interested in to your list
  3. Download your list of interested measures for reference

Performance Year

Select your performance year to view across all tabs.

2018 Quality Measures

50% of final score

This percentage can change due to Special Statuses, Exception Applications, not being scored on any cost measures, or APM participation.

Participants must submit data for at least 6 measures for the 12-month performance period (January 1 - December 31, 2018).

Read more about Quality requirements

Note: This tool does not include these QCDR Measures (XLSX)

284 Quality Measures
  • Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use

     Process
    Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

    Submission Methods

    • Claims
    • Registry
  • Acute Otitis Externa (AOE): Topical Therapy

     Process
    Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations

    Submission Methods

    • Claims
    • Registry
  • Adherence to Antipsychotic Medications For Individuals with Schizophrenia

    High Priority Measure:  Intermediate Outcome
    Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

    Submission Methods

    • Registry
  • Adult Kidney Disease: Blood Pressure Management

    High Priority Measure:  Intermediate Outcome
    Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care

    Submission Methods

    • Registry
  • Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis

    High Priority Measure:  Outcome
    Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated

    Submission Methods

    • Registry
  • Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days

     Outcome
    Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter

    Submission Methods

    • Registry
  • Adult Kidney Disease: Referral to Hospice

    High Priority Measure:  Process
    Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care

    Submission Methods

    • Registry
  • Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

    High Priority Measure:  Process
    Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition

    Submission Methods

    • Registry
  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

     Process
    Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

    Submission Methods

    • EHR

    Documentation

  • Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

    High Priority Measure:  Outcome
    Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery

    Submission Methods

    • Registry
  • Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

    High Priority Measure:  Outcome
    Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

    Submission Methods

    • Registry
  • Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

     Process
    Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

    Submission Methods

    • Registry
  • Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

     Process
    Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis

    Submission Methods

    • Registry
  • Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)

     Efficiency
    Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis

    Submission Methods

    • Registry
  • Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)

     Efficiency
    Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after date of diagnosis

    Submission Methods

    • Registry
  • Age Appropriate Screening Colonoscopy

     Efficiency
    The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31

    Submission Methods

    • Registry
  • Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

     Process
    Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD

    Submission Methods

    • Claims
    • Registry
  • Age-Related Macular Degeneration (AMD): Dilated Macular Examination

     Process
    Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months

    Submission Methods

    • Claims
    • Registry
  • All-cause Hospital Readmission

     Outcome
    The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge

    Submission Methods

    • Administrative Claims

    Documentation

    • Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

      High Priority Measure:  Process
      Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually

      Submission Methods

      • Registry
    • Anastomotic Leak Intervention

      High Priority Measure:  Outcome
      Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery

      Submission Methods

      • Registry
    • Anesthesiology Smoking Abstinence

      High Priority Measure:  Intermediate Outcome
      The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure

      Submission Methods

      • Registry
    • Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

       Process
      Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period

      Submission Methods

      • Registry
    • Anti-Depressant Medication Management

       Process
      Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: a Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)

      Submission Methods

      • EHR

      Documentation

    • Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal

       Process
      Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts

      Submission Methods

      • Registry
    • Appropriate Follow-up Imaging for Incidental Abdominal Lesions

       Process
      Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow_up imaging recommended: Liver lesion =< 0.5 cm; Cystic kidney lesion < 1.0 cm; Adrenal lesion =< 1.0 cm

      Submission Methods

      • Claims
      • Registry
    • Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

       Process
      Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended

      Submission Methods

      • Claims
      • Registry
    • Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

       Process
      Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

      Submission Methods

      • Claims
      • Registry
    • Appropriate Testing for Children with Pharyngitis

       Process
      Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode

      Submission Methods

      • EHR
      • Registry

      Documentation

    • Appropriate Treatment for Children with Upper Respiratory Infection (URI)

       Process
      Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode

      Submission Methods

      • EHR
      • Registry

      Documentation

    • Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia

       Process
      Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy

      Submission Methods

      • Claims
      • Registry
    • Appropriate Work Up Prior to Endometrial Ablation

      High Priority Measure:  Process
      Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation

      Submission Methods

      • Registry
    • Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

       Process
      Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA- approved anticoagulant drug for the prevention of thromboembolism during the measurement period

      Submission Methods

      • Claims
      • Registry
    • Average Change in Back Pain following Lumbar Discectomy / Laminotomy

      High Priority Measure:  Outcome
      The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure

      Submission Methods

      • Registry
    • Average Change in Back Pain following Lumbar Fusion

      High Priority Measure:  Outcome
      The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion procedure

      Submission Methods

      • Registry
    • Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy

      High Priority Measure:  Outcome
      The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure

      Submission Methods

      • Registry
    • Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

       Process
      The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription

      Submission Methods

      • Registry
    • Barrett's Esophagus

       Process
      Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia

      Submission Methods

      • Claims
      • Registry
    • Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician

      High Priority Measure:  Process
      Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist

      Submission Methods

      • Registry
    • Biopsy Follow-Up

      High Priority Measure:  Process
      Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician

      Submission Methods

      • Registry
    • Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

       Process
      Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

      Submission Methods

      • EHR

      Documentation

    • Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

       Process
      Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT

      Submission Methods

      • EHR

      Documentation

    • Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

       Process
      Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

      Submission Methods

      • Claims
      • Registry
    • Breast Cancer Screening

       Process
      Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer

      Submission Methods

      • Claims
      • CMS Web Interface
      • EHR
      • Registry
    • CAHPS for ACO SSM: Access to Specialists

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: Getting Timely Care, Appointments and Information

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: Health Promotion and Education

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: Health Status and Functional Status

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: How Well Providers Communicate

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: Patient’s Rating of Provider

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: Shared Decision-Making

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACO SSM: Stewardship of Patient Resources

      High Priority Measure:  Patient Engagement Experience

      Submission Methods

      • CSV

      Documentation

      Specifications and benchmarking files per measure will be available Summer 2018.

    • CAHPS for ACOs Clinician/Group Survey

      High Priority Measure:  Patient Engagement Experience
      Getting timely care, appointments, and information; How well providers Communicate; Patient's Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; and Stewardship of Patient Resources

      Submission Methods

      • CSV

      Documentation

      • CAHPS for MIPs Clinician/Group Survey

        High Priority Measure:  Patient Engagement Experience
        Getting timely care, appointments, and information; How well providers Communicate; Patient's Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; Courteous and Helpful Office Staff; Care Coordination; and Stewardship of Patient Resources

        Submission Methods

        • CSV

        Documentation

        • Cardiac Rehabilitation Patient Referral from an Outpatient Setting

          High Priority Measure:  Process
          Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program

          Submission Methods

          • Registry
        • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients

           Efficiency
          Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period

          Submission Methods

          • Registry
        • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)

           Efficiency
          Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status

          Submission Methods

          • Registry
        • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

           Efficiency
          Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment

          Submission Methods

          • Registry
        • Care Plan

          High Priority Measure:  Process
          Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

          Submission Methods

          • Claims
          • Registry
        • Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy

          Submission Methods

          • Registry
        • Cataract Surgery: Difference Between Planned and Final Refraction

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction

          Submission Methods

          • Registry
        • Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey

          Submission Methods

          • Registry
        • Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey

          Submission Methods

          • Registry
        • Cervical Cancer Screening

           Process
          Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

          Submission Methods

          • EHR

          Documentation

        • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

          High Priority Measure:  Process
          Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

          Submission Methods

          • EHR

          Documentation

        • Childhood Immunization Status

           Process
          Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

          Submission Methods

          • EHR

          Documentation

        • Children Who Have Dental Decay or Cavities

          High Priority Measure:  Outcome
          Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period

          Submission Methods

          • EHR

          Documentation

        • Chlamydia Screening and Follow Up

           Process
          The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period

          Submission Methods

          • Registry
        • Chlamydia Screening for Women

           Process
          Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period

          Submission Methods

          • EHR

          Documentation

        • Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy

           Process
          Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed an long-acting inhaled bronchodilator

          Submission Methods

          • Claims
          • Registry
        • Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

           Process
          Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented

          Submission Methods

          • Claims
          • Registry
        • Clinical Outcome Post Endovascular Stroke Treatment

          High Priority Measure:  Outcome
          Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention

          Submission Methods

          • Registry
        • Closing the Referral Loop: Receipt of Specialist Report

          High Priority Measure:  Process
          Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use

           Process
          Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy

          Submission Methods

          • Claims
          • Registry
        • Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

           Process
          Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade

          Submission Methods

          • Claims
          • Registry
        • Colorectal Cancer Screening

           Process
          Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older

          High Priority Measure:  Process
          Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication

          Submission Methods

          • Claims
          • Registry
        • Controlling High Blood Pressure

          High Priority Measure:  Intermediate Outcome
          Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention

          Submission Methods

          • Registry
        • Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis

          Submission Methods

          • Registry
        • Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery

           Process
          Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision

          Submission Methods

          • Registry
        • Coronary Artery Bypass Graft (CABG): Prolonged Intubation

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours

          Submission Methods

          • Registry
        • Coronary Artery Bypass Graft (CABG): Stroke

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

          Submission Methods

          • Registry
        • Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason

          Submission Methods

          • Registry
        • Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

           Process
          Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft

          Submission Methods

          • Registry
        • Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

           Process
          Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy

          Submission Methods

          • Registry
        • Coronary Artery Disease (CAD): Antiplatelet Therapy

           Process
          Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel

          Submission Methods

          • Registry
        • Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)

           Process
          Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI OR a current or prior LVEF <40% who were prescribed beta-blocker therapy

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

           Process
          Percentage of patients with dementia for whom there was a documented symptoms screening* for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months

          Submission Methods

          • Registry
        • Dementia: Caregiver Education and Support

          High Priority Measure:  Process
          Percentage of patients with dementia whose caregiver(s)* were provided with education** on dementia disease management and health behavior changes AND were referred to additional resources*** for support in the last 12 months

          Submission Methods

          • Registry
        • Dementia: Cognitive Assessment

           Process
          Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

          Submission Methods

          • EHR

          Documentation

        • Dementia: Functional Status Assessment

           Process
          Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months

          Submission Methods

          • Registry
        • Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia

          High Priority Measure:  Process
          Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation

          Submission Methods

          • Registry
        • Depression Remission at Six Months

          High Priority Measure:  Outcome
          The percentage of patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 30 days) after an index visit

          Submission Methods

          • Registry
        • Depression Remission at Twelve Months

          High Priority Measure:  Outcome
          The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit

          Submission Methods

          • CMS Web Interface
          • EHR
          • Registry

          Documentation

        • Depression Utilization of the PHQ-9 Tool

           Process
          The percentage of patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying visit

          Submission Methods

          • EHR

          Documentation

        • Developmental Screening in the First Three Years of Life

           Process
          The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months proceeding or on their first, second or third birthday

          Submission Methods

          • Registry
        • Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation

           Process
          Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months

          Submission Methods

          • Registry
        • Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear

           Process
          Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing

          Submission Methods

          • Registry
        • Diabetes: Eye Exam

           Process
          Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Diabetes: Foot Exam

           Process
          The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year

          Submission Methods

          • EHR

          Documentation

        • Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

          High Priority Measure:  Intermediate Outcome
          Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Diabetes: Medical Attention for Nephropathy

           Process
          The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

          High Priority Measure:  Process
          Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months

          Submission Methods

          • Claims
          • EHR
          • Registry
        • Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

           Process
          Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months

          Submission Methods

          • EHR

          Documentation

        • Documentation of Current Medications in the Medical Record

          High Priority Measure:  Process
          Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration

          Submission Methods

          • Claims
          • EHR
          • Registry
        • Documentation of Signed Opioid Treatment Agreement

           Process
          All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

          Submission Methods

          • Registry
        • Door to Puncture Time for Endovascular Stroke Treatment

          High Priority Measure:  Intermediate Outcome
          Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours

          Submission Methods

          • Registry
        • Elder Maltreatment Screen and Follow-Up Plan

          High Priority Measure:  Process
          Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen

          Submission Methods

          • Claims
          • Registry
        • Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

          High Priority Measure:  Efficiency
          Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT

          Submission Methods

          • Claims
          • Registry
        • Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years

           Efficiency
          Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury

          Submission Methods

          • Claims
          • Registry
        • Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

           Process
          All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

          Submission Methods

          • Claims
          • Registry
        • Evaluation or Interview for Risk of Opioid Misuse

           Process
          All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

          Submission Methods

          • Registry
        • Falls: Plan of Care

          High Priority Measure:  Process
          Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

          Submission Methods

          • Claims
          • Registry
        • Falls: Risk Assessment

          High Priority Measure:  Process
          Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

          Submission Methods

          • Claims
          • Registry
        • Falls: Screening for Future Fall Risk

          High Priority Measure:  Process
          Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period

          Submission Methods

          • CMS Web Interface
          • EHR

          Documentation

        • Follow-Up After Hospitalization for Mental Illness (FUH)

          High Priority Measure:  Process
          The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: The percentage of discharges for which the patient received follow-up within 30 days of discharge. The percentage of discharges for which the patient received follow-up within 7 days of discharge.

          Submission Methods

          • Registry
        • Follow-Up Care for Children Prescribed ADHD Medication (ADD)

           Process
          Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended

          Submission Methods

          • EHR

          Documentation

        • Functional Outcome Assessment

          High Priority Measure:  Process
          Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

          Submission Methods

          • Claims
          • Registry
        • Functional Status Assessment for Total Hip Replacement

          High Priority Measure:  Process
          Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

          Submission Methods

          • EHR

          Documentation

        • Functional Status Assessment for Total Knee Replacement

          High Priority Measure:  Process
          Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

          Submission Methods

          • EHR

          Documentation

        • Functional Status Assessments for Congestive Heart Failure

          High Priority Measure:  Process
          Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments

          Submission Methods

          • EHR

          Documentation

        • Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

          High Priority Measure:  Outcome
          A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

          Submission Methods

          • Registry
        • Functional Status Change for Patients with Foot or Ankle Impairments

          High Priority Measure:  Outcome
          A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

          Submission Methods

          • Registry
        • Functional Status Change for Patients with Hip Impairments

          High Priority Measure:  Outcome
          A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

          Submission Methods

          • Registry
        • Functional Status Change for Patients with Knee Impairments

          High Priority Measure:  Outcome
          A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

          Submission Methods

          • Registry
        • Functional Status Change for Patients with Lumbar Impairments

          High Priority Measure:  Outcome
          A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality

          Submission Methods

          • Registry
        • Functional Status Change for Patients with Other General Orthopaedic Impairments

          High Priority Measure:  Outcome
          A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality

          Submission Methods

          • Registry
        • Functional Status Change for Patients with Shoulder Impairments

          High Priority Measure:  Outcome
          A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

          Submission Methods

          • Registry
        • Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

           Process
          Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

           Process
          Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry

           Process
          Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart

          Submission Methods

          • Registry
        • Hematology: Multiple Myeloma: Treatment with Bisphosphonates

           Process
          Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period

          Submission Methods

          • Registry
        • Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow

           Process
          Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow

          Submission Methods

          • Registry
        • Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy

           Process
          Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy

          Submission Methods

          • Registry
        • Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options

          High Priority Measure:  Process
          Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment

          Submission Methods

          • Registry
        • Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

           Process
          Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period

          Submission Methods

          • Registry
        • HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies

           Process
          Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies

          Submission Methods

          • Registry
        • HIV Medical Visit Frequency

          High Priority Measure:  Process
          Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits

          Submission Methods

          • Registry
        • HIV Viral Load Suppression

          High Priority Measure:  Outcome
          The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year

          Submission Methods

          • Registry
        • HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis

           Process
          Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis

          Submission Methods

          • EHR

          Documentation

        • HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

           Process
          Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection

          Submission Methods

          • Registry
        • HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

          High Priority Measure:  Outcome
          Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender: Submission Age Criteria 1: Females 18-64 years of age; Submission Age Criteria 2: Males 18-64 years of age; Submission Age Criteria 3: Females 65 years of age and older; Submission Age Criteria 4: Males 65 years of age and older

          Submission Methods

          • Registry
        • HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate

          High Priority Measure:  Outcome
          Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD

          Submission Methods

          • Registry
        • HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

          High Priority Measure:  Outcome
          Infection rate following CIED device implantation, replacement, or revision

          Submission Methods

          • Registry
        • Hypertension: Improvement in Blood Pressure

          High Priority Measure:  Intermediate Outcome
          Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period

          Submission Methods

          • EHR

          Documentation

        • Image Confirmation of Successful Excision of Image-Localized Breast Lesion

          High Priority Measure:  Process
          Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy

          Submission Methods

          • Registry
        • Immunizations for Adolescents

           Process
          The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday

          Submission Methods

          • Registry
        • Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

           Process
          Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy

          Submission Methods

          • Registry
        • Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment

           Process
          Percentage of patients with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the prior or current year are considered adequately screened.

          Submission Methods

          • Registry
        • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

           Process
          Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit

          Submission Methods

          • EHR

          Documentation

        • Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

          High Priority Measure:  Intermediate Outcome
          The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: - Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And - Most recent tobacco status is Tobacco Free -- And - Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And - Statin Use Unless Contraindicated

          Submission Methods

          • Registry
        • Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

           Process
          Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Lung Cancer Reporting (Biopsy/Cytology Specimens)

          High Priority Measure:  Process
          Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary nonsmall cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report

          Submission Methods

          • Claims
          • Registry
        • Lung Cancer Reporting (Resection Specimens)

          High Priority Measure:  Process
          Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type

          Submission Methods

          • Claims
          • Registry
        • Maternal Depression Screening

           Process
          The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life

          Submission Methods

          • EHR

          Documentation

        • Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)

           Outcome
          Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at >= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication

          Submission Methods

          • Registry
        • Maternity Care: Post-Partum Follow-Up and Care Coordination

          High Priority Measure:  Process
          Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning

          Submission Methods

          • Registry
        • Medication Management for People with Asthma

          High Priority Measure:  Process
          The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period

          Submission Methods

          • Registry
        • Medication Reconciliation Post-Discharge

          High Priority Measure:  Process
          The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group: Submission Criteria 1: 18-64 years of age; Submission Criteria 2: 65 years and older; Total Rate: All patients 18 years of age and older

          Submission Methods

          • Claims
          • CMS Web Interface
          • Registry
        • Melanoma Reporting

          High Priority Measure:  Process
          Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate

          Submission Methods

          • Claims
          • Registry
        • Melanoma: Continuity of Care - Recall System

          High Priority Measure:  Structure
          Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: a target date for the next complete physical skin exam, AND a process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment

          Submission Methods

          • Registry
        • Melanoma: Coordination of Care

          High Priority Measure:  Process
          Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis

          Submission Methods

          • Registry
        • Melanoma: Overutilization of Imaging Studies in Melanoma

           Process
          Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered

          Submission Methods

          • Registry
        • Non-Recommended Cervical Cancer Screening in Adolescent Females

           Process
          The percentage of adolescent females 16-20 years of age screened unnecessarily for cervical cancer

          Submission Methods

          • Registry
        • Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

          High Priority Measure:  Process
          Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed

          Submission Methods

          • Claims
          • Registry
        • Oncology: Medical and Radiation - Pain Intensity Quantified

          High Priority Measure:  Process
          Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Oncology: Medical and Radiation - Plan of Care for Pain

          High Priority Measure:  Process
          Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain

          Submission Methods

          • Registry
        • Oncology: Radiation Dose Limits to Normal Tissues

           Process
          Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

          Submission Methods

          • Claims
          • Registry
        • One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

           Process
          Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection

          Submission Methods

          • Registry
        • Operative Mortality Stratified by the Five STS-EACTS Mortality Categories

          High Priority Measure:  Outcome
          Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

          Submission Methods

          • Registry
        • Opioid Therapy Follow-up Evaluation

           Process
          All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

          Submission Methods

          • Registry
        • Optimal Asthma Control

          High Priority Measure:  Outcome
          Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation

          Submission Methods

          • Registry
        • Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

           Process
          Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors

          Submission Methods

          • Registry
        • Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison

          High Priority Measure:  Structure
          Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study

          Submission Methods

          • Registry
        • Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

           Process
          Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study

          Submission Methods

          • Registry
        • Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry

          High Priority Measure:  Structure
          Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements

          Submission Methods

          • Registry
        • Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive

          High Priority Measure:  Structure
          Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

          Submission Methods

          • Registry
        • Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description

          High Priority Measure:  Process
          Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution's computer systems

          Submission Methods

          • Registry
        • Osteoarthritis (OA): Function and Pain Assessment

          High Priority Measure:  Process
          Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain

          Submission Methods

          • Claims
          • Registry
        • Osteoporosis Management in Women Who Had a Fracture

           Process
          The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture

          Submission Methods

          • Claims
          • Registry
        • Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use

          High Priority Measure:  Process
          Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials

          Submission Methods

          • Registry
        • Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination

           Efficiency
          Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered

          Submission Methods

          • Claims
          • Registry
        • Pain Assessment and Follow-Up

          High Priority Measure:  Process
          Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

          Submission Methods

          • Claims
          • Registry
        • Pain Brought Under Control Within 48 Hours

          High Priority Measure:  Outcome
          Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours

          Submission Methods

          • Registry
        • Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment

           Process
          Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed* for cognitive impairment or dysfunction in the past 12 months

          Submission Methods

          • Registry
        • Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease

           Process
          Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed* for psychiatric symptoms** in the past 12 months

          Submission Methods

          • Registry
        • Parkinson's Disease: Rehabilitative Therapy Options

          High Priority Measure:  Process
          Percentage of all patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the past 12 months

          Submission Methods

          • Registry
        • Patient-Centered Surgical Risk Assessment and Communication

          High Priority Measure:  Process
          Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

          Submission Methods

          • Registry
        • Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) 4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies

           Process
          Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies

          Submission Methods

          • Registry
        • Pediatric Kidney Disease: Adequacy of Volume Management

          High Priority Measure:  Process
          Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist

          Submission Methods

          • Registry
        • Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL

          High Priority Measure:  Intermediate Outcome
          Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL

          Submission Methods

          • Registry
        • Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

           Process
          Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines

          Submission Methods

          • Registry
        • Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy

          High Priority Measure:  Process
          Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse

          Submission Methods

          • Claims
          • Registry
        • Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

          High Priority Measure:  Process
          Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse

          Submission Methods

          • Claims
          • Registry
        • Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy

           Process
          Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

          Submission Methods

          • Claims
          • Registry
        • Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin

           Process
          Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis

          Submission Methods

          • Claims
          • Registry
        • Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

          High Priority Measure:  Process
          Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

          Submission Methods

          • Claims
          • Registry
        • Perioperative Temperature Management

          High Priority Measure:  Outcome
          Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

          Submission Methods

          • Registry
        • Persistence of Beta-Blocker Treatment After a Heart Attack

           Process
          The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge

          Submission Methods

          • Registry
        • Photodocumentation of Cecal Intubation

           Process
          The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination

          Submission Methods

          • Claims
          • Registry
        • Pneumococcal Vaccination Status for Older Adults

           Process
          Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)

          High Priority Measure:  Process
          Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU or other non-ICU location in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized

          Submission Methods

          • Registry
        • Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

          High Priority Measure:  Process
          Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member

          Submission Methods

          • Registry
        • Pregnant women that had HBsAg testing

           Process
          This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy

          Submission Methods

          • EHR

          Documentation

        • Preoperative Diagnosis of Breast Cancer

           Process
          The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method

          Submission Methods

          • Registry
        • Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections

          High Priority Measure:  Process
          Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

          Submission Methods

          • Claims
          • Registry
        • Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy

          High Priority Measure:  Process
          Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively

          Submission Methods

          • Registry
        • Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)

           Process
          Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively

          Submission Methods

          • Registry
        • Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

           Process
          Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI >= 18.5 and < 25 kg/m2

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Preventive Care and Screening: Influenza Immunization

           Process
          Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Preventive Care and Screening: Screening for Depression and Follow-Up Plan

           Process
          Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

           Process
          Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

          Submission Methods

          • Claims
          • EHR
          • Registry
        • Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

           Process
          Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

          Submission Methods

          • Claims
          • CMS Web Interface
          • EHR
          • Registry
        • Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

           Process
          Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

          Submission Methods

          • Registry
        • Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists

           Process
          Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period

          Submission Methods

          • EHR

          Documentation

        • Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

           Process
          Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months

          Submission Methods

          • Claims
          • EHR
          • Registry
        • Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within 12 months

          Submission Methods

          • Claims
          • Registry
        • Proportion Admitted to Hospice for less than 3 days

           Outcome
          Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there

          Submission Methods

          • Registry
        • Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life

           Outcome
          Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life

          Submission Methods

          • Registry
        • Proportion Not Admitted To Hospice

           Process
          Proportion of patients who died from cancer not admitted to hospice

          Submission Methods

          • Registry
        • Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

          High Priority Measure:  Outcome
          Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery

          Submission Methods

          • Registry
        • Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

          High Priority Measure:  Outcome
          Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery

          Submission Methods

          • Registry
        • Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair

          High Priority Measure:  Outcome
          Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery

          Submission Methods

          • Registry
        • Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life

           Outcome
          Proportion of patients who died from cancer with more than one emergency room visit in the last 30 days of life

          Submission Methods

          • Registry
        • Proportion Receiving Chemotherapy in the Last 14 Days of Life

           Process
          Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life

          Submission Methods

          • Registry
        • Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

           Process
          Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer

           Process
          Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate

          Submission Methods

          • Registry
        • Psoriasis: Clinical Response to Oral Systemic or Biologic Medications

          High Priority Measure:  Outcome
          Percentage of psoriasis vulgaris patients receiving oral systemic or biologic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment

          Submission Methods

          • Registry
        • Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier

           Process
          Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test

          Submission Methods

          • Registry
        • Quality of Life Assessment For Patients With Primary Headache Disorders

          High Priority Measure:  Outcome
          Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved

          Submission Methods

          • Claims
          • Registry
        • Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients

           Structure
          This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer

          Submission Methods

          • Claims
          • Registry
        • Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

           Process
          Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: Automated exposure control; Adjustment of the mA and/or kV according to patient size; Use of iterative reconstruction technique

          Submission Methods

          • Claims
          • Registry
        • Radical Prostatectomy Pathology Reporting

           Process
          Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status

          Submission Methods

          • Claims
          • Registry
        • Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy

           Process
          Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

          Submission Methods

          • Claims
          • Registry
        • Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms

          High Priority Measure:  Process
          Percentage of final reports for screening mammograms that are classified as "probably benign"

          Submission Methods

          • Claims
          • Registry
        • Radiology: Reminder System for Screening Mammograms

          High Priority Measure:  Structure
          Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram

          Submission Methods

          • Claims
          • Registry
        • Radiology: Stenosis Measurement in Carotid Imaging Reports

           Process
          Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement

          Submission Methods

          • Claims
          • Registry
        • 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

           Process
          Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed

          Submission Methods

          • Registry
        • Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive

          High Priority Measure:  Outcome
          Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery

          Submission Methods

          • Registry
        • Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive

          High Priority Measure:  Outcome
          Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery

          Submission Methods

          • Registry
        • Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

          High Priority Measure:  Outcome
          Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2

          Submission Methods

          • Registry
        • Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)

          High Priority Measure:  Outcome
          Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2

          Submission Methods

          • Registry
        • Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive

          High Priority Measure:  Outcome
          Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive

          Submission Methods

          • Registry
        • 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)

          High Priority Measure:  Outcome
          Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)

          Submission Methods

          • Registry
        • Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive

          High Priority Measure:  Outcome
          Percentage of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive

          Submission Methods

          • Registry
        • 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)

          High Priority Measure:  Outcome
          Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)

          Submission Methods

          • Registry
        • Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure

          High Priority Measure:  Outcome
          Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure

          Submission Methods

          • Claims
          • Registry
        • Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

          High Priority Measure:  Process
          Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness

          Submission Methods

          • Claims
          • Registry
        • Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

           Process
          Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED)

          Submission Methods

          • Claims
          • Registry
        • Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

           Process
          Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months

          Submission Methods

          • Registry
        • Rheumatoid Arthritis (RA): Functional Status Assessment

           Process
          Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months

          Submission Methods

          • Registry
        • Rheumatoid Arthritis (RA): Glucocorticoid Management

           Process
          Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >= 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months

          Submission Methods

          • Registry
        • Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

           Process
          Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months

          Submission Methods

          • Registry
        • Rheumatoid Arthritis (RA): Tuberculosis Screening

           Process
          Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)

          Submission Methods

          • Registry
        • Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

          High Priority Measure:  Outcome
          Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

          Submission Methods

          • Registry
        • Screening Colonoscopy Adenoma Detection Rate

          High Priority Measure:  Outcome
          The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy

          Submission Methods

          • Registry
        • Screening for Osteoporosis for Women Aged 65-85 Years of Age

           Process
          Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis

          Submission Methods

          • Claims
          • Registry
        • Sentinel Lymph Node Biopsy for Invasive Breast Cancer

           Process
          The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure

          Submission Methods

          • Registry
        • Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

           Process
          Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured

          Submission Methods

          • Registry
        • Sleep Apnea: Assessment of Sleep Symptoms

           Process
          Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness

          Submission Methods

          • Registry
        • Sleep Apnea: Positive Airway Pressure Therapy Prescribed

           Process
          Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy

          Submission Methods

          • Registry
        • Sleep Apnea: Severity Assessment at Initial Diagnosis

           Process
          Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

          Submission Methods

          • Registry
        • Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

           Process
          Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge

          Submission Methods

          • Registry
        • Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

           Process
          Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged >=21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL; OR Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

          Submission Methods

          • CMS Web Interface
          • EHR
          • Registry

          Documentation

        • Stroke and Stroke Rehabilitation: Thrombolytic Therapy

           Process
          Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well

          Submission Methods

          • Registry
        • Surgical Site Infection (SSI)

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

          Submission Methods

          • Registry
        • Tobacco Use and Help with Quitting Among Adolescents

           Process
          The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

          Submission Methods

          • Registry
        • Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report

          High Priority Measure:  Process
          Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant

          Submission Methods

          • Registry
        • Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet

          High Priority Measure:  Process
          Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet

          Submission Methods

          • Registry
        • Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

          High Priority Measure:  Process
          Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure

          Submission Methods

          • Registry
        • Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

          High Priority Measure:  Process
          Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)

          Submission Methods

          • Registry
        • Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy

           Process
          Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) - III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab

          Submission Methods

          • Registry
        • Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

           Process
          Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location

          Submission Methods

          • Claims
          • Registry
        • Unplanned Hospital Readmission within 30 Days of Principal Procedure

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure

          Submission Methods

          • Registry
        • Unplanned Reoperation within the 30 Day Postoperative Period

          High Priority Measure:  Outcome
          Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period

          Submission Methods

          • Registry
        • Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

           Process
          Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months

          Submission Methods

          • Claims
          • Registry
        • Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

          High Priority Measure:  Process
          Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months

          Submission Methods

          • Claims
          • Registry
        • Use of High-Risk Medications in the Elderly

          High Priority Measure:  Process
          Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication. 2) Percentage of patients who were ordered at least two of the same high-risk medication

          Submission Methods

          • EHR
          • Registry

          Documentation

        • Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

          High Priority Measure:  Process
          The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries

          Submission Methods

          • Registry
        • Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

           Outcome
          Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment

          Submission Methods

          • Registry
        • Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

           Process
          Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity

          Submission Methods

          • EHR

          Documentation