downloadchevron-downchevron-rightchevron-with-circle-downchevron-with-circle-upcheckcircle-with-minuscircle-with-plusexporthelp-with-circleinboxlinkmailold-phonestar-outlinedstaruserv-cardcloseclosecloseBack to top
Top

Explore Measures

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.

2019 Quality Measures

45% of final score

This percentage can change due to Special Statuses, Exception Applications, reweighting of other performance categories, or Alternative Payment Model (APM) participation.

Participants collect measure data for the 12-month performance period (January 1 - December 31, 2019). The amount of data that must be submitted depends on the collection (measure) type.

Read more about Quality requirements

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

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

    High Priority Measure:  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

    Documentation

    • Acute Otitis Externa (AOE): Topical Therapy

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

      Submission Methods

      • Claims
      • Registry

      Documentation

      • 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

        Documentation

        • 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

          Documentation

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

            High Priority Measure:  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

            Documentation

            • 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

              Documentation

              • 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

                Documentation

                • 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

                    Documentation

                    • 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

                      Documentation

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

                        High Priority Measure:  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

                        Documentation

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

                          High Priority Measure:  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

                          Documentation

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

                            High Priority Measure:  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

                            Documentation

                            • Advance 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 or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

                              Submission Methods

                              • Claims
                              • Registry

                              Documentation

                              • Age Appropriate Screening Colonoscopy

                                High Priority Measure:  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

                                Documentation

                                • 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 the 12 month performance period

                                  Submission Methods

                                  • Claims
                                  • Registry

                                  Documentation

                                  • All-cause Hospital Readmission

                                    High Priority Measure:  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

                                      Documentation

                                      • 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

                                        Documentation

                                        • 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

                                          Documentation

                                          • 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

                                            Documentation

                                            • 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

                                                Documentation

                                                • Appropriate Follow-up Imaging for Incidental Abdominal Lesions

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

                                                  Submission Methods

                                                  • Claims
                                                  • Registry

                                                  Documentation

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

                                                    High Priority Measure:  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

                                                    Documentation

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

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

                                                      Submission Methods

                                                      • Claims
                                                      • Registry

                                                      Documentation

                                                      • Appropriate Testing for Children with Pharyngitis

                                                        High Priority Measure:  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

                                                        Documentation

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

                                                          High Priority Measure:  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

                                                          Documentation

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

                                                            High Priority Measure:  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

                                                            Documentation

                                                            • Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

                                                              High Priority Measure:  Process
                                                              Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.

                                                              Submission Methods

                                                              • EHR

                                                              Documentation

                                                              • Appropriate Workup 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

                                                                Documentation

                                                                • 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 oral anticoagulant drug for the prevention of thromboembolism during the measurement period

                                                                  Submission Methods

                                                                  • Claims
                                                                  • Registry

                                                                  Documentation

                                                                  • 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 a lumbar discectomy/laminotomy procedure

                                                                    Submission Methods

                                                                    • Registry

                                                                    Documentation

                                                                    • 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 a lumbar fusion procedure

                                                                      Submission Methods

                                                                      • Registry

                                                                      Documentation

                                                                      • Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery

                                                                        High Priority Measure:  Outcome
                                                                        The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure

                                                                        Submission Methods

                                                                        • Registry

                                                                        Documentation

                                                                        • Average Change in Functional Status Following Lumbar Fusion Surgery

                                                                          High Priority Measure:  Outcome
                                                                          The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2. 1a) for patients 18 years of age and older who had a lumbar fusion procedure

                                                                          Submission Methods

                                                                          • Registry

                                                                          Documentation

                                                                          • Average Change In Functional Status Following Total Knee Replacement Surgery

                                                                            High Priority Measure:  Outcome
                                                                            The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement

                                                                            Submission Methods

                                                                            • Registry

                                                                            Documentation

                                                                            • 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 a lumbar discectomy/laminotomy procedure

                                                                              Submission Methods

                                                                              • Registry

                                                                              Documentation

                                                                              • Average Change in Leg Pain Following Lumbar Fusion Surgery

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

                                                                                Submission Methods

                                                                                • Registry

                                                                                Documentation

                                                                                • Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

                                                                                  High Priority Measure:  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

                                                                                  Documentation

                                                                                  • 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

                                                                                    Documentation

                                                                                    • 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

                                                                                      Documentation

                                                                                      • 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

                                                                                        Submission Methods

                                                                                        • Registry

                                                                                        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 (indicated by HCPCS code) and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT

                                                                                          Submission Methods

                                                                                          • EHR

                                                                                          Documentation

                                                                                          • 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

                                                                                            Documentation

                                                                                            • CAHPS for MIPs Clinician/Group Survey

                                                                                              High Priority Measure:  Patient Engagement Experience
                                                                                              The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: - Getting timely care, appointments, and information;- How well providers Communicate;- Patient's Rating of Provider;- Access to Specialists;- Health Promotion & Education;- Shared Decision Making;- Health Status/Functional Status;- Courteous and Helpful Office Staff;- Care Coordination; and- Stewardship of Patient Resources

                                                                                              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

                                                                                                Documentation

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

                                                                                                  High Priority Measure:  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

                                                                                                  Documentation

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

                                                                                                    High Priority Measure:  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

                                                                                                    Documentation

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

                                                                                                      High Priority Measure:  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

                                                                                                      Documentation

                                                                                                      • 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

                                                                                                        Documentation

                                                                                                        • 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

                                                                                                          Documentation

                                                                                                          • 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

                                                                                                            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

                                                                                                              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

                                                                                                                Documentation

                                                                                                                • Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

                                                                                                                  High Priority Measure:  Patient Engagement Experience
                                                                                                                  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

                                                                                                                  Documentation

                                                                                                                  • 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 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 a long-acting inhaled bronchodilator

                                                                                                                              Submission Methods

                                                                                                                              • Claims
                                                                                                                              • Registry

                                                                                                                              Documentation

                                                                                                                              • 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

                                                                                                                                Documentation

                                                                                                                                • 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

                                                                                                                                  Documentation

                                                                                                                                  • 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

                                                                                                                                    Documentation

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

                                                                                                                                      High Priority Measure:  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

                                                                                                                                      • Registry

                                                                                                                                      Documentation

                                                                                                                                      • Colorectal Cancer Screening

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

                                                                                                                                        Submission Methods

                                                                                                                                        • Claims
                                                                                                                                        • CMS Web Interface
                                                                                                                                        • EHR

                                                                                                                                        Documentation

                                                                                                                                        • 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 submitted by the physician who treats the fracture and who therefore is held accountable for the communication

                                                                                                                                          Submission Methods

                                                                                                                                          • Claims
                                                                                                                                          • Registry

                                                                                                                                          Documentation

                                                                                                                                          • Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

                                                                                                                                            High Priority Measure:  Process
                                                                                                                                            Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment

                                                                                                                                            Submission Methods

                                                                                                                                            • Registry

                                                                                                                                            Documentation

                                                                                                                                            • 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 (< 140/90 mmHg) during the measurement period

                                                                                                                                              Submission Methods

                                                                                                                                              • Claims
                                                                                                                                              • CMS Web Interface
                                                                                                                                              • EHR

                                                                                                                                              Documentation

                                                                                                                                              • 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

                                                                                                                                                Documentation

                                                                                                                                                • 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

                                                                                                                                                  Documentation

                                                                                                                                                  • 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

                                                                                                                                                    Documentation

                                                                                                                                                    • 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

                                                                                                                                                      Documentation

                                                                                                                                                      • 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

                                                                                                                                                        Documentation

                                                                                                                                                        • 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

                                                                                                                                                          Documentation

                                                                                                                                                          • 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

                                                                                                                                                            Documentation

                                                                                                                                                            • 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

                                                                                                                                                              Documentation

                                                                                                                                                              • 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

                                                                                                                                                                Documentation

                                                                                                                                                                • Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

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

                                                                                                                                                                  Submission Methods

                                                                                                                                                                  • Registry

                                                                                                                                                                  Documentation

                                                                                                                                                                  • 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: Education and Support of Caregivers for Patients with Dementia

                                                                                                                                                                      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

                                                                                                                                                                      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

                                                                                                                                                                        Documentation

                                                                                                                                                                        • Dementia: Safety Concern Screening and Follow-Up 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

                                                                                                                                                                          Submission Methods

                                                                                                                                                                          • Registry

                                                                                                                                                                          Documentation

                                                                                                                                                                          • Depression Remission at Six Months

                                                                                                                                                                            High Priority Measure:  Outcome
                                                                                                                                                                            The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 60 days) after an index event date

                                                                                                                                                                            Submission Methods

                                                                                                                                                                            • Registry

                                                                                                                                                                            Documentation

                                                                                                                                                                            • Depression Remission at Twelve Months

                                                                                                                                                                              High Priority Measure:  Outcome
                                                                                                                                                                              The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event

                                                                                                                                                                              Submission Methods

                                                                                                                                                                              • CMS Web Interface
                                                                                                                                                                              • EHR

                                                                                                                                                                              Documentation

                                                                                                                                                                              • Depression Utilization of the PHQ-9 Tool

                                                                                                                                                                                 Process
                                                                                                                                                                                The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter

                                                                                                                                                                                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 preceding or on their first, second or third birthday

                                                                                                                                                                                  Submission Methods

                                                                                                                                                                                  • Registry

                                                                                                                                                                                  Documentation

                                                                                                                                                                                  • 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

                                                                                                                                                                                    Documentation

                                                                                                                                                                                    • 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

                                                                                                                                                                                      Documentation

                                                                                                                                                                                      • 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 or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period

                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                        • Claims
                                                                                                                                                                                        • 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

                                                                                                                                                                                          Documentation

                                                                                                                                                                                          • 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

                                                                                                                                                                                            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

                                                                                                                                                                                              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

                                                                                                                                                                                                Documentation

                                                                                                                                                                                                • Documentation of Signed Opioid Treatment Agreement

                                                                                                                                                                                                  High Priority Measure:  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

                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                  • 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

                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                    • 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

                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                      • 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 with a minor blunt head trauma 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

                                                                                                                                                                                                        Documentation

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

                                                                                                                                                                                                          High Priority Measure:  Efficiency
                                                                                                                                                                                                          Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury

                                                                                                                                                                                                          Submission Methods

                                                                                                                                                                                                          • Claims
                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                          • 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

                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                            • Evaluation or Interview for Risk of Opioid Misuse

                                                                                                                                                                                                              High Priority Measure:  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

                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                      • 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 Phaseb. 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

                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                          • 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) 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 patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.) The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                  Submission Methods

                                                                                                                                                                                                                                  • Registry

                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                  • Functional Status Change for Patients with General Orthopedic Impairments

                                                                                                                                                                                                                                    High Priority Measure:  Outcome
                                                                                                                                                                                                                                    A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                    • Registry

                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                    • Functional Status Change for Patients with Hip Impairments

                                                                                                                                                                                                                                      High Priority Measure:  Outcome
                                                                                                                                                                                                                                      A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                      Submission Methods

                                                                                                                                                                                                                                      • Registry

                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                      • Functional Status Change for Patients with Knee Impairments

                                                                                                                                                                                                                                        High Priority Measure:  Outcome
                                                                                                                                                                                                                                        A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                        • Functional Status Change for Patients with Low Back Impairments

                                                                                                                                                                                                                                          High Priority Measure:  Outcome
                                                                                                                                                                                                                                          A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                          Submission Methods

                                                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                          • Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments

                                                                                                                                                                                                                                            High Priority Measure:  Outcome
                                                                                                                                                                                                                                            A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                            Submission Methods

                                                                                                                                                                                                                                            • Registry

                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                            • Functional Status Change for Patients with Shoulder Impairments

                                                                                                                                                                                                                                              High Priority Measure:  Outcome
                                                                                                                                                                                                                                              A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.).The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

                                                                                                                                                                                                                                              Submission Methods

                                                                                                                                                                                                                                              • Registry

                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                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

                                                                                                                                                                                                                                                  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

                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                            • 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 submission period

                                                                                                                                                                                                                                                              Submission Methods

                                                                                                                                                                                                                                                              • Registry

                                                                                                                                                                                                                                                              Documentation

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

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

                                                                                                                                                                                                                                                                Submission Methods

                                                                                                                                                                                                                                                                • Registry

                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                  • HIV Screening

                                                                                                                                                                                                                                                                     Process
                                                                                                                                                                                                                                                                    Percentage of patients 15-65 years of age who have been tested for human immunodeficiency virus (HIV).

                                                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                                                    • EHR

                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                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

                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                  • Immunizations for Adolescents

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

                                                                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                                                                    • Registry

                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                      Documentation

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

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

                                                                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                        • 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 diagnosisb. 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 or equal to 140/90 mm Hg -- AND- Most recent tobacco status is Tobacco Free -- AND- Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND- Statin Use Unless Contraindicated

                                                                                                                                                                                                                                                                                            Submission Methods

                                                                                                                                                                                                                                                                                            • Registry

                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                            • Lung Cancer Reporting (Biopsy/Cytology Specimens)

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

                                                                                                                                                                                                                                                                                              Submission Methods

                                                                                                                                                                                                                                                                                              • Claims
                                                                                                                                                                                                                                                                                              • Registry

                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                • 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)

                                                                                                                                                                                                                                                                                                    High Priority Measure:  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

                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                        • 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 recordThis 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
                                                                                                                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                          • Melanoma Reporting

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

                                                                                                                                                                                                                                                                                                            Submission Methods

                                                                                                                                                                                                                                                                                                            • Claims
                                                                                                                                                                                                                                                                                                            • Registry

                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                • Non-Recommended Cervical Cancer Screening in Adolescent Females

                                                                                                                                                                                                                                                                                                                  High Priority Measure:  Process
                                                                                                                                                                                                                                                                                                                  The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer

                                                                                                                                                                                                                                                                                                                  Submission Methods

                                                                                                                                                                                                                                                                                                                  • Registry

                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                  • 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, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed

                                                                                                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                                                                                                    • Claims
                                                                                                                                                                                                                                                                                                                    • Registry

                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                      Documentation

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

                                                                                                                                                                                                                                                                                                                        High Priority Measure:  Process
                                                                                                                                                                                                                                                                                                                        Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician

                                                                                                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                            • Opioid Therapy Follow-up Evaluation

                                                                                                                                                                                                                                                                                                                              High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                                                Documentation

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

                                                                                                                                                                                                                                                                                                                                  High Priority Measure:  Process
                                                                                                                                                                                                                                                                                                                                  Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians)

                                                                                                                                                                                                                                                                                                                                  Submission Methods

                                                                                                                                                                                                                                                                                                                                  • Registry

                                                                                                                                                                                                                                                                                                                                  Documentation

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

                                                                                                                                                                                                                                                                                                                                    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

                                                                                                                                                                                                                                                                                                                                    Documentation

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

                                                                                                                                                                                                                                                                                                                                      High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                      • 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 submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements

                                                                                                                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                          • Osteoporosis Management in Women Who Had a Fracture

                                                                                                                                                                                                                                                                                                                                             Process
                                                                                                                                                                                                                                                                                                                                            The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture

                                                                                                                                                                                                                                                                                                                                            Submission Methods

                                                                                                                                                                                                                                                                                                                                            • Claims
                                                                                                                                                                                                                                                                                                                                            • Registry

                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                            • Otitis Media with Effusion: 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

                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                              • Overuse of Imaging for the Evaluation of Primary Headache

                                                                                                                                                                                                                                                                                                                                                High Priority Measure:  Process
                                                                                                                                                                                                                                                                                                                                                Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present

                                                                                                                                                                                                                                                                                                                                                Submission Methods

                                                                                                                                                                                                                                                                                                                                                • Claims
                                                                                                                                                                                                                                                                                                                                                • Registry

                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                    • Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease

                                                                                                                                                                                                                                                                                                                                                       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

                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                        • 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 (i.e., physical, occupational, and speech therapy) discussed in the past 12 months

                                                                                                                                                                                                                                                                                                                                                          Submission Methods

                                                                                                                                                                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                            • Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies

                                                                                                                                                                                                                                                                                                                                                              High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                    • Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)

                                                                                                                                                                                                                                                                                                                                                                      High Priority Measure:  Outcome
                                                                                                                                                                                                                                                                                                                                                                      Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there

                                                                                                                                                                                                                                                                                                                                                                      Submission Methods

                                                                                                                                                                                                                                                                                                                                                                      • Registry

                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                      • Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better)

                                                                                                                                                                                                                                                                                                                                                                        High Priority Measure:  Outcome
                                                                                                                                                                                                                                                                                                                                                                        Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life

                                                                                                                                                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                        • Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score - better)

                                                                                                                                                                                                                                                                                                                                                                          High Priority Measure:  Process
                                                                                                                                                                                                                                                                                                                                                                          Percentage of patients who died from cancer not admitted to hospice

                                                                                                                                                                                                                                                                                                                                                                          Submission Methods

                                                                                                                                                                                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                          • Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better)

                                                                                                                                                                                                                                                                                                                                                                            High Priority Measure:  Process
                                                                                                                                                                                                                                                                                                                                                                            Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life

                                                                                                                                                                                                                                                                                                                                                                            Submission Methods

                                                                                                                                                                                                                                                                                                                                                                            • Registry

                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                            • Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score - better)

                                                                                                                                                                                                                                                                                                                                                                              High Priority Measure:  Outcome
                                                                                                                                                                                                                                                                                                                                                                              Percentage of patients who died from cancer with more than one emergency department visit in the last 30 days of life

                                                                                                                                                                                                                                                                                                                                                                              Submission Methods

                                                                                                                                                                                                                                                                                                                                                                              • Registry

                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                                                                                                Documentation

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

                                                                                                                                                                                                                                                                                                                                                                                  High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                      • 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 adiagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge

                                                                                                                                                                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                        • Photodocumentation of Cecal Intubation

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

                                                                                                                                                                                                                                                                                                                                                                                          Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                          • Claims
                                                                                                                                                                                                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                          • 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
                                                                                                                                                                                                                                                                                                                                                                                            • EHR

                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                              • 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 and/or intraoperatively

                                                                                                                                                                                                                                                                                                                                                                                                Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                • Registry

                                                                                                                                                                                                                                                                                                                                                                                                Documentation

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

                                                                                                                                                                                                                                                                                                                                                                                                  High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                  • 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 encounterNormal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

                                                                                                                                                                                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                    • Claims
                                                                                                                                                                                                                                                                                                                                                                                                    • EHR

                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                        • 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 reporting 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

                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                  • 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 the 12 month performance period

                                                                                                                                                                                                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                    • Claims
                                                                                                                                                                                                                                                                                                                                                                                                                    • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                    • 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 30 days after surgery

                                                                                                                                                                                                                                                                                                                                                                                                                      Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                      • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                      • 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 30 days after surgery

                                                                                                                                                                                                                                                                                                                                                                                                                        Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                        • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                        • Proportion of Patients Sustaining a Ureter Injury at the Time of 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 30 days after surgery

                                                                                                                                                                                                                                                                                                                                                                                                                          Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                          • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

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

                                                                                                                                                                                                                                                                                                                                                                                                                            High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                                                                                                            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

                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                              • Psoriasis: Clinical Response to Systemic Medications

                                                                                                                                                                                                                                                                                                                                                                                                                                High Priority Measure:  Outcome
                                                                                                                                                                                                                                                                                                                                                                                                                                Percentage of psoriasis vulgaris patients receiving systemic 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

                                                                                                                                                                                                                                                                                                                                                                                                                                • Claims
                                                                                                                                                                                                                                                                                                                                                                                                                                • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                                Documentation

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

                                                                                                                                                                                                                                                                                                                                                                                                                                   Process
                                                                                                                                                                                                                                                                                                                                                                                                                                  Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test

                                                                                                                                                                                                                                                                                                                                                                                                                                  Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                  • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                        • Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy

                                                                                                                                                                                                                                                                                                                                                                                                                                          High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                              • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                              • Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                              • 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 of disease activity at >=50% of encounters for RA for each patient during the measurement year

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • Rheumatoid Arthritis (RA): Tuberculosis Screening

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Process
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who havedocumentation of a tuberculosis (TB) screening performed and results interpreted within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              • 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 were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR*Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • CMS Web Interface
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • EHR

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

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

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          • 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 medication2) Percentage of patients who were ordered at least two of the same high-risk medication

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            • EHR

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            • Uterine Artery Embolization Technique: Documenttion of Angigraphic 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              • Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                High Priority Measure:  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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Documentation

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                • 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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • Zoster (Shingles) Vaccination

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Process
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    The percentage of patients aged 50 years and older who have had a Varicella Zoster (shingles) vaccination.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Submission Methods

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • Registry

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Documentation