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Quality Measures

Instructions

  1. Review and select measures that best fit your practice.
  2. Add up to six measures from the list below, including one outcome measure. You can use the search and filters to help find the measures that meet your needs or specialty.
  3. If an outcome measure is not available that is applicable to your specialty or practice, chose another high priority measure.
  4. Download a CSV file of the measures you have selected for your records.

Groups in APMs qualifying for special scoring standards under MIPS, such as Shared Savings Program Track 1 or the Oncology Care Model: Report quality measures through your APM. You do not need to do anything additional for the MIPS quality category.

Clinicians reporting with electronic clinical quality measures (eCQMs): Review the eCQM Implementation Checklist and download the technical specifications for eCQMs on the eCQI Resource Center.

Note: This tool is only for informational and estimation purposes. You can’t use it to submit or attest to measures or activities.

2017 MIPS Performance

Select Measures

Showing271Measures

Selected Measures

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Once you select measures, they will appear here.

Disclaimer

*MIPS eligible clinicians or groups are expected to report on applicable measures. “Applicable” is defined as measures relevant to a particular MIPS eligible clinician’s services or care rendered. MIPS eligible clinicians can refer to the measures specifications to verify which measures are applicable. Not all measures in each Specialty Measure Set will be applicable to all clinicians in a given specialty. If the set includes less than six applicable measures, the eligible clinician should only report the measures that are applicable.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0654
  • Quality ID: 093
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Emergency Medicine
  • Otolaryngology
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0653
  • Quality ID: 091
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Emergency Medicine
  • Otolaryngology
  • Pediatrics
Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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.

Measure Number
  • eMeasure ID: CMS136v6
  • eMeasure NQF: N/A
  • NQF: 0108
  • Quality ID: 366
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Mental/Behavioral Health
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1879
  • Quality ID: 383
NQS Domain

Patient Safety

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Mental/Behavioral Health
Primary Measure Steward

Health Services Advisory Group

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 122
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Renal Physicians Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 329
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Renal Physicians Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 330
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Renal Physicians Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 403
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Renal Physicians Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 325
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Mental/Behavioral Health
Primary Measure Steward

American Psychiatric Association

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

Measure Number
  • eMeasure ID: CMS161v5
  • eMeasure NQF: N/A
  • NQF: 0104
  • Quality ID: 107
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 384
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 385
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 331
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 332
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 333
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 334
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 439
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Gastroenterological Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0566
  • Quality ID: 140
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0087
  • Quality ID: 014
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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.

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1789
  • Quality ID: 458
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

No

Data Submission Method
  • Administrative Claims
Specialty Measure Set

N/A

Primary Measure Steward

Yale University

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 386
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 354
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Surgery
Primary Measure Steward

American College of Surgeons

The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 404
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Anesthesiology
Primary Measure Steward

American Society of Anesthesiologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 387
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

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).

Measure Number
  • eMeasure ID: CMS128v5
  • eMeasure NQF: N/A
  • NQF: 0105
  • Quality ID: 009
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Internal Medicine
  • Mental/Behavioral Health
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 421
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Interventional Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 405
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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 or ultrasound of the 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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 406
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0658
  • Quality ID: 320
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Gastroenterological Association

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

Measure Number
  • eMeasure ID: CMS146v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 066
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • Emergency Medicine
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS154v5
  • eMeasure NQF: N/A
  • NQF: 0069
  • Quality ID: 065
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 407
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Hospitalists
Primary Measure Steward

Infectious Diseases Society of America

Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy before undergoing an endometrial ablation

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0567
  • Quality ID: 448
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1525
  • Quality ID: 326
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • General Practice/Family Medicine
Primary Measure Steward

American College of Cardiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0058
  • Quality ID: 116
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Emergency Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1854
  • Quality ID: 249
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 440
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 265
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Dermatology
  • Interventional Radiology
  • Obstetrics/Gynecology
  • Urology
Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: CMS169v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 367
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

Center for Quality Assessment and Improvement in Mental Health

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0391
  • Quality ID: 099
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

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

Measure Number
  • eMeasure ID: CMS125v5
  • eMeasure NQF: N/A
  • NQF: 2372
  • Quality ID: 112
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Obstetrics/Gynecology
  • Preventive Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

Getting timely care, appointments, and information; How well providers Communicate; Patient's Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; Courteous and Helpful Office Staff; Care Coordination; Between Visit Communication; Helping Your to Take Medication as Directed; and Stewardship of Patient Resources

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0006 & 0005
  • Quality ID: 321
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Patient Engagement/Experience

High Priority Measure

Yes

Data Submission Method
  • CSV
Specialty Measure Set
  • General Practice/Family Medicine
Primary Measure Steward

Agency for Healthcare Research & Quality

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0643
  • Quality ID: 243
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American College of Cardiology Foundation

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 322
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Cardiology
Primary Measure Steward

American College of Cardiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 323
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Cardiology
Primary Measure Steward

American College of Cardiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 324
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Cardiology
Primary Measure Steward

American College of Cardiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0326
  • Quality ID: 047
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • Emergency Medicine
  • Gastroenterology
  • General Surgery
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS133v5
  • eMeasure NQF: N/A
  • NQF: 0565
  • Quality ID: 191
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS132v5
  • eMeasure NQF: N/A
  • NQF: 0564
  • Quality ID: 192
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1536
  • Quality ID: 303
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 304
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 389
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 388
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: CMS124v5
  • eMeasure NQF: N/A
  • NQF: 0032
  • Quality ID: 309
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Obstetrics/Gynecology
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS177v5
  • eMeasure NQF: N/A
  • NQF: 1365
  • Quality ID: 382
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set
  • Mental/Behavioral Health
  • Pediatrics
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS117v5
  • eMeasure NQF: N/A
  • NQF: 0038
  • Quality ID: 240
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS75v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 378
NQS Domain

Community/Population Health

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 447
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS153v5
  • eMeasure NQF: N/A
  • NQF: 0033
  • Quality ID: 310
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Obstetrics/Gynecology
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0102
  • Quality ID: 052
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Thoracic Society

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0091
  • Quality ID: 051
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Thoracic Society

Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 409
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Interventional Radiology

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

Measure Number
  • eMeasure ID: CMS50v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 374
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set
  • Allergy/Immunology
  • Cardiology
  • Dermatology
  • Emergency Medicine
  • Gastroenterology
  • General Surgery
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0659
  • Quality ID: 185
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Gastroenterological Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0392
  • Quality ID: 100
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

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

Measure Number
  • eMeasure ID: CMS130v5
  • eMeasure NQF: N/A
  • NQF: 0034
  • Quality ID: 113
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0045
  • Quality ID: 024
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Preventive Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS165v5
  • eMeasure NQF: N/A
  • NQF: 0018
  • Quality ID: 236
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • Obstetrics/Gynecology
  • Preventive Medicine
  • Thoracic Surgery
  • Vascular Surgery
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0130
  • Quality ID: 165
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Thoracic Surgery
Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0114
  • Quality ID: 167
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Thoracic Surgery
Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0236
  • Quality ID: 044
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Anesthesiology
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0129
  • Quality ID: 164
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Thoracic Surgery
Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0131
  • Quality ID: 166
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Thoracic Surgery
Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0115
  • Quality ID: 168
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Thoracic Surgery
Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0134
  • Quality ID: 043
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0066
  • Quality ID: 118
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Cardiology
Primary Measure Steward

American Heart Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0067
  • Quality ID: 006
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Cardiology
Primary Measure Steward

American Heart Association

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

Measure Number
  • eMeasure ID: CMS145v5
  • eMeasure NQF: N/A
  • NQF: 0070
  • Quality ID: 007
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • Cardiology
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 288
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
  • Mental/Behavioral Health
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: CMS149v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 281
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Neurology
  • Mental/Behavioral Health
Primary Measure Steward

Physician Consortium for Performance Improvement

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 286
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
  • Mental/Behavioral Health
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 282
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
  • Mental/Behavioral Health
Primary Measure Steward

American Academy of Neurology

Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 284
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
  • Mental/Behavioral Health
Primary Measure Steward

American Academy of Neurology

Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 283
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
  • Mental/Behavioral Health
Primary Measure Steward

American Academy of Neurology

Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0711
  • Quality ID: 411
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Mental/Behavioral Health
Primary Measure Steward

Minnesota Community Measurement

Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

Measure Number
  • eMeasure ID: CMS159v5
  • eMeasure NQF: N/A
  • NQF: 0710
  • Quality ID: 370
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Mental/Behavioral Health
  • General Practice/Family Medicine
Primary Measure Steward

Minnesota Community Measurement

Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit

Measure Number
  • eMeasure ID: CMS160v5
  • eMeasure NQF: N/A
  • NQF: 0712
  • Quality ID: 371
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Mental/Behavioral Health
Primary Measure Steward

Minnesota Community Measurement

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

Measure Number
  • eMeasure ID: CMS131v5
  • eMeasure NQF: N/A
  • NQF: 0055
  • Quality ID: 117
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Ophthalmology
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: CMS123v5
  • eMeasure NQF: N/A
  • NQF: 0056
  • Quality ID: 163
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Internal Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

Measure Number
  • eMeasure ID: CMS122v5
  • eMeasure NQF: N/A
  • NQF: 0059
  • Quality ID: 001
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Preventive Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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.

Measure Number
  • eMeasure ID: CMS134v5
  • eMeasure NQF: N/A
  • NQF: 0062
  • Quality ID: 119
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0417
  • Quality ID: 126
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Podiatric Medical Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0416
  • Quality ID: 127
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Podiatric Medical Association

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

Measure Number
  • eMeasure ID: CMS142v5
  • eMeasure NQF: N/A
  • NQF: 0089
  • Quality ID: 019
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • EHR
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS167v5
  • eMeasure NQF: N/A
  • NQF: 0088
  • Quality ID: 018
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS68v6
  • eMeasure NQF: N/A
  • NQF: 0419
  • Quality ID: 130
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • EHR
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Anesthesiology
  • Cardiology
  • Dermatology
  • Emergency Medicine
  • Gastroenterology
  • General Surgery
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
  • General Practice/Family Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

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.

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 412
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Neurology
  • Physical Medicine
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Neurology

Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 413
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Interventional Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 181
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Mental/Behavioral Health
  • General Practice/Family Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 415
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Emergency Medicine
Primary Measure Steward

American College of Emergency Physicians

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 416
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Emergency Medicine
Primary Measure Steward

American College of Emergency Physicians

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1814
  • Quality ID: 268
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 414
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Neurology
  • Physical Medicine
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0101
  • Quality ID: 155
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0101
  • Quality ID: 154
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

Measure Number
  • eMeasure ID: CMS139v5
  • eMeasure NQF: N/A
  • NQF: 0101
  • Quality ID: 318
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • CMS Web Interface
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

National Committee for Quality Assurance

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: The percentage of discharges for which the patient received follow-up within 30 days of discharge. The percentage of discharges for which the patient received follow-up within 7 days of discharge

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0576
  • Quality ID: 391
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Mental/Behavioral Health
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2624
  • Quality ID: 182
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Physical Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments

Measure Number
  • eMeasure ID: CMS56v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 376
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set
  • Orthopedic Surgery
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments

Measure Number
  • eMeasure ID: CMS66v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 375
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set
  • Orthopedic Surgery
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments

Measure Number
  • eMeasure ID: CMS90v6
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 377
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0427
  • Quality ID: 222
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0424
  • Quality ID: 219
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0428
  • Quality ID: 223
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0423
  • Quality ID: 218
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0422
  • Quality ID: 217
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0425
  • Quality ID: 220
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0426
  • Quality ID: 221
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Focus on Therapeutic Outcomes, Inc.

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

Measure Number
  • eMeasure ID: CMS135v5
  • eMeasure NQF: 2907
  • NQF: 0081
  • Quality ID: 005
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • Hospitalists
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS144v5
  • eMeasure NQF: 2908
  • NQF: 0083
  • Quality ID: 008
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • Cardiology
  • Hospitalists
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0379
  • Quality ID: 070
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0380
  • Quality ID: 069
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society of Hematology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0377
  • Quality ID: 067
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society of Hematology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0378
  • Quality ID: 068
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society of Hematology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 390
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Gastroenterological Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 401
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Gastroenterology
  • General Practice/Family Medicine
Primary Measure Steward

American Gastroenterological Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1857
  • Quality ID: 449
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: CMS52v5
  • eMeasure NQF: N/A
  • NQF: 0405
  • Quality ID: 160
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Allergy/Immunology
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0409
  • Quality ID: 205
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2079
  • Quality ID: 340
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Health Resources and Services Administration

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2082
  • Quality ID: 338
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Practice/Family Medicine
Primary Measure Steward

Health Resources and Services Administration

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2474
  • Quality ID: 392
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Electrophysiology Cardiac Specialist
Primary Measure Steward

The Heart Rhythm Society

Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 348
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Electrophysiology Cardiac Specialist
Primary Measure Steward

The Heart Rhythm Society

Infection rate following CIED device implantation, replacement, or revision

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 393
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Electrophysiology Cardiac Specialist
Primary Measure Steward

The Heart Rhythm Society

Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Measure Number
  • eMeasure ID: CMS65v6
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 373
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 262
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society of Breast Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1407
  • Quality ID: 394
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 275
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Gastroenterological Association

Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 271
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Gastroenterological Association

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

Measure Number
  • eMeasure ID: CMS137v5
  • eMeasure NQF: N/A
  • NQF: 0004
  • Quality ID: 305
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 441
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Wisconsin Collaborative for Healthcare Quality

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

Measure Number
  • eMeasure ID: CMS164v5
  • eMeasure NQF: N/A
  • NQF: 0068
  • Quality ID: 204
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1859
  • Quality ID: 451
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 395
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 396
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

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

Measure Number
  • eMeasure ID: CMS82v4
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 372
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 335
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 336
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1799
  • Quality ID: 444
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0097
  • Quality ID: 046
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • CMS Web Interface
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0650
  • Quality ID: 137
NQS Domain

Communication and Care Coordination

Measure Type

Structure

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Dermatology
Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 138
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Dermatology
Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0562
  • Quality ID: 224
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Dermatology
Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 397
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 443
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 147
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

Society of Nuclear Medicine and Molecular Imaging

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

Measure Number
  • eMeasure ID: CMS157v5
  • eMeasure NQF: N/A
  • NQF: 0384
  • Quality ID: 143
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • General Oncology
  • Radiation Oncology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0383
  • Quality ID: 144
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Radiation Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0382
  • Quality ID: 156
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Radiation Oncology
Primary Measure Steward

American Society for Radiation Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 400
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0733
  • Quality ID: 446
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 408
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Neurology
  • Physical Medicine
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 398
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • General Practice/Family Medicine
Primary Measure Steward

Minnesota Community Measurement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 364
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 362
NQS Domain

Communication and Care Coordination

Measure Type

Structure

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 360
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 361
NQS Domain

Patient Safety

Measure Type

Structure

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 363
NQS Domain

Communication and Care Coordination

Measure Type

Structure

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 359
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 109
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Orthopedic Surgery
  • Physical Medicine
  • Preventive Medicine
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Orthopedic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0053
  • Quality ID: 418
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Obstetrics/Gynecology
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 419
NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0420
  • Quality ID: 131
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Physical Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 342
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Practice/Family Medicine
Primary Measure Steward

National Hospice and Palliative Care Organization

All patients with a diagnosis of Parkinson's disease who were assessed for cognitive impairment or dysfunction in the last 12 months

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 291
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

All patients with a diagnosis of Parkinson's disease (or caregiver(s), as appropriate) who had the Parkinson's disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least annually

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 294
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

All patients with a diagnosis of Parkinson's disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 290
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

All patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 293
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 358
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Surgery
  • Orthopedic Surgery
  • Otolaryngology
  • Thoracic Surgery
  • Urology
  • Plastic Surgery
Primary Measure Steward

American College of Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1860
  • Quality ID: 452
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 327
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Renal Physicians Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1667
  • Quality ID: 328
NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Renal Physicians Association

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 428
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Urogynecologic Society

Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 429
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Urogynecologic Society

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2063
  • Quality ID: 422
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
Primary Measure Steward

American Urogynecologic Society

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0465
  • Quality ID: 423
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society for Vascular Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0268
  • Quality ID: 021
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • General Surgery
  • Orthopedic Surgery
  • Otolaryngology
  • Thoracic Surgery
  • Plastic Surgery
Primary Measure Steward

American Society of Plastic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0239
  • Quality ID: 023
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • General Surgery
  • Orthopedic Surgery
  • Otolaryngology
  • Thoracic Surgery
  • Plastic Surgery
Primary Measure Steward

American Society of Plastic Surgeons

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 recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2671
  • Quality ID: 424
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Anesthesiology
Primary Measure Steward

American Society of Anesthesiologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0071
  • Quality ID: 442
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 425
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society for Gastrointestinal Endoscopy

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

Measure Number
  • eMeasure ID: CMS127v5
  • eMeasure NQF: N/A
  • NQF: 0043
  • Quality ID: 111
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Preventive Medicine
Primary Measure Steward

National Committee for Quality Assurance

Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 426
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Anesthesiology
Primary Measure Steward

American Society of Anesthesiologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 427
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Anesthesiology
Primary Measure Steward

American Society of Anesthesiologists

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

Measure Number
  • eMeasure ID: CMS158v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 369
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set

N/A

Primary Measure Steward

OptumInsight

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 263
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society of Breast Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 076
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Anesthesiology
  • Hospitalists
Primary Measure Steward

American Society of Anesthesiologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 430
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Anesthesiology
Primary Measure Steward

American Society of Anesthesiologists

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

Measure Number
  • eMeasure ID: CMS69v5
  • eMeasure NQF: N/A
  • NQF: 0421
  • Quality ID: 128
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • Gastroenterology
  • General Surgery
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
  • General Practice/Family Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: CMS147v6
  • eMeasure NQF: N/A
  • NQF: 0041
  • Quality ID: 110
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Obstetrics/Gynecology
  • Preventive Medicine
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS2v6
  • eMeasure NQF: N/A
  • NQF: 0418
  • Quality ID: 134
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Mental/Behavioral Health
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: CMS22v5
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 317
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • EHR
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Anesthesiology
  • Cardiology
  • Dermatology
  • Emergency Medicine
  • Gastroenterology
  • General Surgery
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
  • General Practice/Family Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: CMS138v5
  • eMeasure NQF: N/A
  • NQF: 0028
  • Quality ID: 226
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • CMS Web Interface
  • EHR
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Cardiology
  • Dermatology
  • Emergency Medicine
  • Gastroenterology
  • General Surgery
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 2152
  • Quality ID: 431
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • Emergency Medicine
  • Gastroenterology
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Mental/Behavioral Health
  • General Practice/Family Medicine
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: CMS74v6
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 379
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Pediatrics
Primary Measure Steward

Centers for Medicare & Medicaid Services

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

Measure Number
  • eMeasure ID: CMS143v5
  • eMeasure NQF: N/A
  • NQF: 0086
  • Quality ID: 012
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • EHR
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0563
  • Quality ID: 141
NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Ophthalmology
Primary Measure Steward

American Academy of Ophthalmology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0216
  • Quality ID: 457
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0213
  • Quality ID: 455
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

Proportion of patients who died from cancer not admitted to hospice

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0215
  • Quality ID: 456
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 432
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
Primary Measure Steward

American Urogynecologic Society

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 433
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
Primary Measure Steward

American Urogynecologic Society

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 434
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
Primary Measure Steward

American Urogynecologic Society

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0211
  • Quality ID: 454
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0210
  • Quality ID: 453
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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 adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0390
  • Quality ID: 104
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Urology
Primary Measure Steward

American Urological Association Education and Research

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

Measure Number
  • eMeasure ID: CMS129v6
  • eMeasure NQF: N/A
  • NQF: 0389
  • Quality ID: 102
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set
  • General Oncology
  • Radiation Oncology
  • Urology
Primary Measure Steward

Physician Consortium for Performance Improvement

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 410
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Dermatology
Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 435
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Neurology
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1855
  • Quality ID: 251
NQS Domain

Effective Clinical Care

Measure Type

Structure

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Pathology
Primary Measure Steward

College of American Pathologists

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 436
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1853
  • Quality ID: 250
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • General Oncology
  • Pathology
Primary Measure Steward

College of American Pathologists

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)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 145
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

Percentage of final reports for screening mammograms that are classified as "probably benign"

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0508
  • Quality ID: 146
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0509
  • Quality ID: 225
NQS Domain

Communication and Care Coordination

Measure Type

Structure

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0507
  • Quality ID: 195
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Diagnostic Radiology
Primary Measure Steward

American College of Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 344
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Interventional Radiology
  • Vascular Surgery
Primary Measure Steward

Society for Vascular Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 260
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Vascular Surgery
Primary Measure Steward

Society for Vascular Surgeons

Percent of patients undergoing endovascular repair of small or moderate infrarenal abdominal aortic aneurysms (AAA) that die while in the hospital

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1534
  • Quality ID: 347
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Vascular Surgery
Primary Measure Steward

Society for Vascular Surgeons

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)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 259
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Interventional Radiology
  • Vascular Surgery
Primary Measure Steward

Society for Vascular Surgeons

Percentage of patients undergoing open repair of small or moderate abdominal aortic aneurysms (AAA) who are discharged alive

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1523
  • Quality ID: 417
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society for Vascular Surgeons

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)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 258
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Vascular Surgery
Primary Measure Steward

Society for Vascular Surgeons

Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1543
  • Quality ID: 345
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Interventional Radiology
  • Vascular Surgery
Primary Measure Steward

Society for Vascular Surgeons

Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1540
  • Quality ID: 346
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society for Vascular Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 437
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Interventional Radiology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 261
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Audiology Quality Consortium

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 179
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
  • Rheumatology
Primary Measure Steward

American College of Rheumatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 178
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
  • Rheumatology
Primary Measure Steward

American College of Rheumatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 180
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
  • Rheumatology
Primary Measure Steward

American College of Rheumatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 177
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Rheumatology
Primary Measure Steward

American College of Rheumatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 176
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Rheumatology
Primary Measure Steward

American College of Rheumatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 255
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Emergency Medicine
Primary Measure Steward

American College of Emergency Physicians

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0119
  • Quality ID: 445
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Thoracic Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 343
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Gastroenterology
Primary Measure Steward

American Society for Gastrointestinal Endoscopy

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0046
  • Quality ID: 039
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Preventive Medicine
Primary Measure Steward

National Committee for Quality Assurance

The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 264
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Society of Breast Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 279
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Academy of Sleep Medicine

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 276
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Academy of Sleep Medicine

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 278
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Academy of Sleep Medicine

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 277
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Academy of Sleep Medicine

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1519
  • Quality ID: 257
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society for Vascular Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 438
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • CMS Web Interface
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Cardiology
  • General Practice/Family Medicine
Primary Measure Steward

Centers for Medicare & Medicaid Services

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed antithrombotic therapy at discharge

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 032
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Hospitalists
  • Neurology
Primary Measure Steward

American Academy of Neurology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 187
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

American Heart Association

Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 357
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Surgery
  • Otolaryngology
  • Vascular Surgery
  • Plastic Surgery
Primary Measure Steward

American College of Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 402
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Allergy/Immunology
  • Internal Medicine
  • Cardiology
  • Dermatology
  • Emergency Medicine
  • Gastroenterology
  • General Surgery
  • General Oncology
  • Hospitalists
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
  • Mental/Behavioral Health
  • Plastic Surgery
  • General Practice/Family Medicine
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 353
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
Primary Measure Steward

American Association of Hip and Knee Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 352
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
Primary Measure Steward

American Association of Hip and Knee Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 350
NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
Primary Measure Steward

American Association of Hip and Knee Surgeons

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)

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 351
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • Orthopedic Surgery
Primary Measure Steward

American Association of Hip and Knee Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 1858
  • Quality ID: 450
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Oncology
Primary Measure Steward

American Society of Clinical Oncology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 337
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set
  • Dermatology
  • Rheumatology
  • General Practice/Family Medicine
Primary Measure Steward

American Academy of Dermatology

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: 0651
  • Quality ID: 254
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Emergency Medicine
Primary Measure Steward

American College of Emergency Physicians

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 356
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Surgery
Primary Measure Steward

American College of Surgeons

Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 355
NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method
  • Registry
Specialty Measure Set
  • General Surgery
Primary Measure Steward

American College of Surgeons

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 048
NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Obstetrics/Gynecology
  • Preventive Medicine
  • Urology
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 050
NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • Claims
  • Registry
Specialty Measure Set
  • Internal Medicine
  • Obstetrics/Gynecology
  • Urology
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.

Measure Number
  • eMeasure ID: CMS156v5
  • eMeasure NQF: N/A
  • NQF: 0022
  • Quality ID: 238
NQS Domain

Patient Safety

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

National Committee for Quality Assurance

Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.

Measure Number
  • eMeasure ID: CMS166v6
  • eMeasure NQF: N/A
  • NQF: 0052
  • Quality ID: 312
NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method
  • EHR
Specialty Measure Set
  • Orthopedic Surgery
  • Physical Medicine
  • General Practice/Family Medicine
Primary Measure Steward

National Committee for Quality Assurance

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

Measure Number
  • eMeasure ID: N/A
  • eMeasure NQF: N/A
  • NQF: N/A
  • Quality ID: 420
NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

No

Data Submission Method
  • Registry
Specialty Measure Set

N/A

Primary Measure Steward

Society of Interventional Radiology

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

Measure Number
  • eMeasure ID: CMS155v5
  • eMeasure NQF: N/A
  • NQF: 0024
  • Quality ID: 239
NQS Domain

Community/Population Health

Measure Type

Process

High Priority Measure

No

Data Submission Method
  • EHR
Specialty Measure Set
  • Pediatrics
Primary Measure Steward

National Committee for Quality Assurance