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Explore Measures & Activities

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.

2020 Quality Measures

45% of final score

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

You must collect measure data for the 12-month performance period (January 1 - December 31, 2020). The amount of data that you must submit (“data completeness”) depends on the collection (measure) type.

Read more about Quality requirements

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

219 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.

    Collection Type and 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).

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

    • Administrative claims measures No documentation available
  • 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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).

    Collection Type and 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.

    Collection Type and Documentation

  • Appropriate Follow-up Imaging for Incidental Abdominal Lesions

    High Priority Measure:  Process
    Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow_up imaging recommended based on radiological findings:- Cystic renal lesion that is simple appearing* (Bosniak I or II)- Adrenal lesion less than or equal to 1.0 cm- Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols

    Collection Type and 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.

    Collection Type and 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 polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Appropriate Workup Prior to Endometrial Ablation

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Back Pain After Lumbar Discectomy/Laminectomy

    High Priority Measure:  Patient Reported Outcome
    For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.

    Collection Type and Documentation

  • Back Pain After Lumbar Fusion

    High Priority Measure:  Patient Reported Outcome
    For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively.* hereafter referred to as VAS Pain

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

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

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

    Collection Type and Documentation

  • Breast Cancer Screening

     Process
    Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.

    Collection Type and Documentation

  • CAHPS for ACOs Clinician/Group Survey

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

    Collection Type and Documentation

    • CAHPS for MIPS survey No documentation available
  • 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; (Not endorsed by NQF)- How well Providers Communicate; (Not endorsed by NQF)- Patient's Rating of Provider; (NQF endorsed # 0005)- Access to Specialists; (Not endorsed by NQF)- Health Promotion and Education; (Not endorsed by NQF)- Shared Decision-Making; (Not endorsed by NQF) - Health Status and Functional Status; (Not endorsed by NQF)- Courteous and Helpful Office Staff; (NQF endorsed # 0005)- Care Coordination; (Not endorsed by NQF)- Stewardship of Patient Resources. (Not endorsed by NQF)

    Collection Type and Documentation

    • CAHPS for MIPS survey No documentation available
  • 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • 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

    Collection Type and 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.

    Collection Type and Documentation

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

    High Priority Measure:  Outcome
    Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract 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 in the operative eye within 90 days following the cataract surgery.

    Collection Type and Documentation

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

    High Priority Measure:  Patient Reported 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 or four 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.

    Collection Type and Documentation

  • Colorectal Cancer Screening

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Controlling High Blood Pressure

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 date.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Diabetes: Eye Exam

     Process
    Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 MIPS 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

     Process
    Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.

    Collection Type and 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, Screener and Opioid Assessment for Patients with Pain, revised (SOAPP-R)) or patient interview documented at least once during Opioid Therapy in the medical record.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: - The percentage of discharges for which the patient received follow-up within 30 days after discharge. - The percentage of discharges for which the patient received follow-up within 7 days after discharge.

    Collection Type and 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 Phase.b) Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

    Collection Type and 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.

    Collection Type and Documentation

  • Functional Status After Lumbar Discectomy/Laminectomy

    High Priority Measure:  Patient Reported Outcome
    For patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively.

    Collection Type and Documentation

  • Functional Status After Lumbar Fusion

    High Priority Measure:  Patient Reported Outcome
    For patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a)* at one year (9 to 15 months) postoperatively.

    Collection Type and Documentation

  • Functional Status After Primary Total Knee Replacement

    High Priority Measure:  Patient Reported Outcome
    For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) at one year (9 to 15 months) postoperatively.

    Collection Type and 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.

    Collection Type and 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) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.

    Collection Type and 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.

    Collection Type and Documentation

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

    High Priority Measure:  Patient Reported 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) (©2009-2019 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 measure).

    Collection Type and Documentation

  • Functional Status Change for Patients with Hip Impairments

    High Priority Measure:  Patient Reported 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) (©2009-2019 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 measure).

    Collection Type and Documentation

  • Functional Status Change for Patients with Knee Impairments

    High Priority Measure:  Patient Reported 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) (©2009-2019 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 measure).

    Collection Type and Documentation

  • Functional Status Change for Patients with Low Back Impairments

    High Priority Measure:  Patient Reported 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) (©2009-2019 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 measure).

    Collection Type and Documentation

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

    High Priority Measure:  Patient Reported 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) (©2009-2019 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 measure).

    Collection Type and Documentation

  • Functional Status Change for Patients with Neck Impairments

    High Priority Measure:  Patient Reported Outcome
    This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14+ with neck impairments. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality. *The Neck FS PROM is an item-response theory-based computer adaptive test (CAT). In addition to the CAT version, which provides for reduced patient response burden, it is available as a 10-item short form (static/paper-pencil).

    Collection Type and Documentation

  • Functional Status Change for Patients with Shoulder Impairments

    High Priority Measure:  Patient Reported 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) (©2009-2019 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 measure).

    Collection Type and Documentation

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

     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 or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.

    Collection Type and 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.

    Collection Type and Documentation

    • Electronic clinical quality measures (eCQMs) Specifications  
    • MIPS clinical quality measures (MIPS CQMs) No documentation available
  • 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • HIV Screening

     Process
    Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Immunizations for Adolescents

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

    Collection Type and Documentation

  • 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.

    Collection Type and Documentation

  • 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

    High Priority Measure:  Process
    Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis.b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.

    Collection Type and Documentation

  • International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

    High Priority Measure:  Patient Reported Outcome
    Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.

    Collection Type and 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

    Collection Type and Documentation

  • Leg Pain After Lumbar Discectomy/Laminectomy

    High Priority Measure:  Patient Reported Outcome
    For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS Pain scale at three months (6 to 20 weeks) postoperatively.

    Collection Type and Documentation

  • Leg Pain After Lumbar Fusion

    High Priority Measure:  Patient Reported Outcome
    For patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively. * hereafter referred to as VAS Pain.

    Collection Type and 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 non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.

    Collection Type and 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 (NSCLC), histologic type.

    Collection Type and Documentation

  • Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 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 < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication.

    Collection Type and Documentation

  • Maternity Care: Postpartum 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 postpartum care within 8 weeks of giving birth and who received a breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.

    Collection Type and Documentation

  • Medication Management for People with Asthma

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Multimodal Pain Management

    High Priority Measure:  Process
    Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

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

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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).

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Pneumococcal Vaccination Status for Older Adults

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 encounter.

    Collection Type and 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.

    Collection Type and 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 or 14 days prior to 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 eligible encounter.

    Collection Type and 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 submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.

    Collection Type and 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 usera. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months.b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention.c. 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 who did not have a bone scan performed at any time since diagnosis of prostate cancer.

    Collection Type and 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.

    Collection Type and Documentation

  • Psoriasis: Clinical Response to Systemic Medications

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

    Collection Type and 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/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through 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.

    Collection Type and Documentation

  • Quality of Life Assessment For Patients With Primary Headache Disorders

    High Priority Measure:  Patient Reported 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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).

    Collection Type and 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".

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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).

    Collection Type and 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).

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.

    Collection Type and 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 using an ACR-preferred RA disease activity assessment tool at >=50% of encounters for RA for each patient during the measurement year.

    Collection Type and Documentation

  • Rheumatoid Arthritis (RA): Tuberculosis Screening

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

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and Documentation

  • Skin Cancer: 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), or melanoma (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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 alteplase was initiated within three hours of time last known well.

    Collection Type and Documentation

  • Surgical Site Infection (SSI)

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

    Collection Type and 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.

    Collection Type and 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., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.

    Collection Type and 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).

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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.

    Collection Type and 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 medication.2) Percentage of patients who were ordered at least two of the same high-risk medications.

    Collection Type and Documentation

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

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

    Collection Type and Documentation

  • Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

    High Priority Measure:  Patient Reported 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.

    Collection Type and 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.

    Collection Type and Documentation