2016 ACO Quality Measures

We track your Clinical Quality Measure performance throughout the reporting period, compare your performance to peer benchmarks, and provide you with improvement resources.

Together, we can increase the value of your ACO.

Talk to a PRO

Web-Interface Measures

These measures can be used by ACOs (MSSP and Pioneer) and practices that have opted for the Web-Interface GPRO method of PQRS reporting. ACO PRO automates the submission of these measures to the CMS Web-Interface.

Claims Measures

These measures can be used by ACOs (MSSP and Pioneer). ACO PRO will aggregate your data, to help monitor and improve your performance throughout the year.

CAHPS Measures

These measures can be used by ACOs (MSSP and Pioneer). To report survey measures successfully, ACOs must use a CMS approved CAHPS vendor to report these measures.

Who do these measures apply to?

  • Pioneer ACOs
  • The Medicare Shared Savings Program ACOs
  • Practices that opted to report PQRS through the GPRO Web-Interface use just the ACO Web-Interface Measures

What are the reporting requirements for 2016?

Web Interface Measures for ACOs and GPRO (Web-Interface Option)


Measure Title


Care Coordination/Patient Safety (CARE) Measures
(2 Measures – Individually Sampled)
ACO-13 Falls: Screening for Future Fall Risk CARE-2
ACO 39 Documentation of Current Medications in the Medical Record CARE-3
Coronary Artery Disease (CAD) Disease Module (1 Measure)
ACO-33 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) CAD-7
Diabetes Composite
(2 Components of 1 Composite Measure)
Composite: (All or Nothing Scoring)
ACO-27 Composite (All or Nothing Scoring): Diabetes: Hemoglobin A1c Poor Control DM-2
ACO-41 Composite (All or Nothing Scoring): Diabetes: Eye Exam DM-7
Heart Failure (HF) Disease Module (1 Measure)
ACO 31 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) HF-6
Hypertension (HTN) Disease Module (1 Measure)
AC0 28 Controlling High Blood Pressure HTN-2
Ischemic Vascular Disease (IVD) Disease Module (1 Measure)
ACO 30 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic IVD-2
Mental Health (MH) Disease Module (1 Measure)
ACO 40 Depression Remission at Twelve Months MH-1
Preventive (PREV) Care Measures (9 Measures – Individually Sampled)
ACO 20 Breast Cancer Screening PREV-5
ACO 19 Colorectal Cancer Screening PREV-6
ACO 14 Preventive Care and Screening: Influenza Immunization PREV-7
ACO 15 Pneumonia Vaccination Status for Older Adults PREV-8
ACO 16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan PREV-9
ACO 17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention PREV-10
ACO 21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented PREV-11
ACO 18 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan PREV-12
ACO 42 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease PREV-13

Claims Submission Measures for ACOs

For the claims-based measures, ACOs do not need to collect or submit additional data aside from normal billing activities. The CMS ACO Program Analysis Contractor (ACO PAC) will coordinate with CMS to obtain the necessary Medicare claims files and calculate the rates for these measures for each ACO.

For the electronic health record (EHR) measure, the CMS ACO PAC will calculate the measure using CMS claims and administrative data extracted from the National Level Repository. The National Level Repository contains administrative data for the Medicare & Medicaid EHR Incentive Program. Given the different timelines for updating the National Level Repository data (especially from the state Medicaid incentive programs), CMS encourages all eligible providers within the ACOs to successfully attest to the 2016 EHR Incentive program as early as feasible. [source]



Measure Title

ACO-8 Risk standardized all condition readmission
ACO-9 Ambulatory Sensitive conditions admissions: chronic obstructive pulmonary disease (COPD) or asthma in older adults
ACO-10 Ambulatory sensitive conditions admissions: heart failure (HF)
ACO-35 Skilled nursing facility 30-day all-cause readmission measures (SNFRM)
ACO-36 All-cause unplanned admissions for patients with diabetes
ACO-37 All-cause unplanned admissions for patients with heart failure
ACO-38 All-cause unplanned admissions for patients with multiple chronic conditions
ACO-11 Percent of primary care physicians who successfully meet Meaningful Use requirements (EHR Incentive Program Data)

Survey Measures for ACOs


Measure Title

ACO-1 CAHPS: Getting timely care, appointments, and information
ACO-2 CAHPS: How well your providers communicate
ACO-3 CAHPS: Patients’ rating of provider
ACO-4 CAHPS: Access to specialists
ACO-5 CAHPS: Health promotion and education
ACO-6 CAHPS: Shared decision making
ACO-7 CAHPS: Health status/functional status
ACO-34 CAHPS: Stewardship of patient resources

Contact Us