009 Anti-depressant Medication Management Process eCQM Details ecqm 012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Process eCQM Details ecqm 107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Process eCQM Details ecqm 239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Process eCQM Details ecqm 240 Childhood Immunization Status Process eCQM Details ecqm 281 Dementia: Cognitive Assessment Process eCQM Details ecqm ecqm-mvp mvp 305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Process eCQM Details ecqm 309 Cervical Cancer Screening Process eCQM Details ecqm ecqm-mvp mvp 310 Chlamydia Screening for Women Process eCQM Details ecqm ecqm-mvp mvp 318 Falls: Screening for Future Fall Risk Process eCQM Details ecqm 366 Follow-Up Care for Children Prescribed ADHD Medication (ADD) Process eCQM Details ecqm 375 Functional Status Assessment for Total Knee Replacement Process eCQM Details ecqm 376 Functional Status Assessment for Total Hip Replacement Process eCQM Details ecqm ecqm-mvp mvp 377 Functional Status Assessments for Heart Failure Process eCQM Details ecqm ecqm-mvp mvp 378 Children Who Have Dental Decay or Cavities Outcome eCQM Details ecqm 379 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Process eCQM Details ecqm 382 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment Process eCQM Details ecqm 462 Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy Process eCQM Details ecqm ecqm-mvp mvp 472 Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture Process eCQM Details ecqm 475 HIV Screening Process eCQM Details ecqm ecqm-mvp mvp 476 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia Patient Reported Outcome Performance eCQM Details ecqm 481 Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer Process eCQM Details ecqm 001 Diabetes: Hemoglobin A1c Poor Control Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 005 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 006 Coronary Artery Disease (CAD): Antiplatelet Therapy Process CQM, MVP Details cqm cqm-mvp mvp 007 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%) Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 039 Screening for Osteoporosis for Women Aged 65-85 Years of Age Process CQM, MVP Details cqm cqm-mvp mvp 047 Advance Care Plan Process CQM, MVP Details cqm cqm-mvp mvp 110 Preventive Care and Screening: Influenza Immunization Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 111 Pneumococcal Vaccination Status for Older Adults Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 112 Breast Cancer Screening Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 014 Age-Related Macular Degeneration (AMD): Dilated Macular Examination Process CQM Details cqm 019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Process CQM, eCQM Details cqm cqm-ecqm ecqm 048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older Process CQM Details cqm 050 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older Process CQM Details cqm 052 Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy Process CQM Details cqm 065 Appropriate Treatment for Upper Respiratory Infection (URI) Process CQM, eCQM Details cqm cqm-ecqm ecqm 066 Appropriate Testing for Pharyngitis Process CQM, eCQM Details cqm cqm-ecqm ecqm 093 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use Process CQM Details cqm 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Process CQM, eCQM Details cqm cqm-ecqm ecqm 104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer Process CQM Details cqm 113 Colorectal Cancer Screening Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 116 Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis Process CQM, MVP Details cqm cqm-mvp mvp 118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF <= 40%) Process CQM, MVP Details cqm cqm-mvp mvp 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 130 Documentation of Current Medications in the Medical Record Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 143 Oncology: Medical and Radiation – Pain Intensity Quantified Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 144 Oncology: Medical and Radiation – Plan of Care for Pain Process CQM, MVP Details cqm cqm-mvp mvp 117 Diabetes: Eye Exam Process CQM, eCQM Details cqm cqm-ecqm ecqm 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation Process CQM Details cqm 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear Process CQM Details cqm 137 Melanoma: Continuity of Care – Recall System Process CQM Details cqm 138 Melanoma: Coordination of Care Process CQM Details cqm 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Outcome CQM Details cqm 145 Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy Process CQM Details cqm 147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy Process CQM Details cqm 155 Falls: Plan of Care Process CQM Details cqm 164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation Outcome CQM Details cqm 167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure Outcome CQM Details cqm 168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration Outcome CQM Details cqm 176 Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy Process CQM, MVP Details cqm cqm-mvp mvp 177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity Process CQM, MVP Details cqm cqm-mvp mvp 178 Rheumatoid Arthritis (RA): Functional Status Assessment Process CQM, MVP Details cqm cqm-mvp mvp 180 Rheumatoid Arthritis (RA): Glucocorticoid Management Process CQM, MVP Details cqm cqm-mvp mvp 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy Process CQM, MVP Details cqm cqm-mvp mvp 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 236 Controlling High Blood Pressure Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 238 Use of High-Risk Medications in Older Adults Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting Process CQM, MVP Details cqm cqm-mvp mvp 181 Elder Maltreatment Screen and Follow-Up Plan Process CQM Details cqm 182 Functional Outcome Assessment Process CQM Details cqm 185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use Process CQM Details cqm 191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Outcome CQM, eCQM Details cqm cqm-ecqm ecqm 205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis Process CQM Details cqm 217 Functional Status Change for Patients with Knee Impairments Outcome CQM Details cqm 218 Functional Status Change for Patients with Hip Impairments Outcome CQM Details cqm 219 Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments Outcome CQM Details cqm 220 Functional Status Change for Patients with Low Back Impairments Outcome CQM Details cqm 221 Functional Status Change for Patients with Shoulder Impairments Outcome CQM Details cqm 249 Barrett’s Esophagus Process CQM Details cqm 254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Process CQM, MVP Details cqm cqm-mvp mvp 268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy Process CQM, MVP Details cqm cqm-mvp mvp 282 Dementia: Functional Status Assessment Process CQM, MVP Details cqm cqm-mvp mvp 286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia Process CQM, MVP Details cqm cqm-mvp mvp 288 Dementia: Education and Support of Caregivers for Patients with Dementia Process CQM, MVP Details cqm cqm-mvp mvp 290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease Process CQM, MVP Details cqm cqm-mvp mvp 291 Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease Process CQM, MVP Details cqm cqm-mvp mvp 293 Rehabilitative Therapy Referral for Patients with Parkinson’s Disease Process CQM, MVP Details cqm cqm-mvp mvp 250 Radical Prostatectomy Pathology Reporting Process CQM Details cqm 259 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome CQM Details cqm 260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome CQM Details cqm 261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness Process CQM Details cqm 264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer Process CQM Details cqm 275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy Process CQM Details cqm 277 Sleep Apnea: Severity Assessment at Initial Diagnosis Process CQM Details cqm 279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy Process CQM Details cqm 283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management Process CQM Details cqm 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Process CQM, eCQM Details cqm cqm-ecqm ecqm 320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Process CQM Details cqm 322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients Process CQM Details cqm 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Process CQM, MVP Details cqm cqm-mvp mvp 331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) Process CQM, MVP Details cqm cqm-mvp mvp 344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome CQM, MVP Details cqm cqm-mvp mvp 350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Nonsurgical) Therapy Process CQM, MVP Details cqm cqm-mvp mvp 351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation Process CQM, MVP Details cqm cqm-mvp mvp 324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients Process CQM Details cqm 332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Process CQM Details cqm 335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) Outcome CQM Details cqm 336 Maternity Care: Postpartum Follow-Up and Care Coordination Process CQM Details cqm 338 HIV Viral Load Suppression Outcome CQM Details cqm 340 HIV Medical Visit Frequency Process CQM Details cqm 354 Anastomotic Leak Intervention Outcome CQM Details cqm 355 Unplanned Reoperation within the 30 Day Postoperative Period Outcome CQM Details cqm 356 Unplanned Hospital Readmission within 30 Days of Principal Procedure Outcome CQM Details cqm 357 Surgical Site Infection (SSI) Outcome CQM Details cqm 358 Patient-Centered Surgical Risk Assessment and Communication Process CQM Details cqm 360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies Process CQM Details cqm 364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines Process CQM Details cqm 370 Depression Remission at Twelve Months Outcome CQM, eCQM Details cqm cqm-ecqm ecqm 374 Closing the Referral Loop: Receipt of Specialist Report Process CQM, eCQM Details cqm cqm-ecqm ecqm 386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Process CQM, MVP Details cqm cqm-mvp mvp 392 HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation Outcome CQM, MVP Details cqm cqm-mvp mvp 393 HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Outcome CQM, MVP Details cqm cqm-mvp mvp 398 Optimal Asthma Control Outcome CQM, MVP Details cqm cqm-mvp mvp 400 One-Time Screening for Hepatitis C Virus (HCV) for all Patients Process CQM, MVP Details cqm cqm-mvp mvp 404 Anesthesiology Smoking Abstinence Process CQM, MVP Details cqm-mvp 409 Clinical Outcome Post-Endovascular Stroke Treatment Outcome CQM, MVP Details cqm cqm-mvp mvp 383 Adherence to Antipsychotic Medications for Individuals with Schizophrenia Process CQM Details cqm 384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery Outcome CQM Details cqm 385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Outcome CQM Details cqm 387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users Process CQM Details cqm 389 Cataract Surgery: Difference Between Planned and Final Refraction Outcome CQM Details cqm 394 Immunizations for Adolescents Process CQM Details cqm 395 Lung Cancer Reporting (Biopsy/Cytology Specimens) Process CQM Details cqm 396 Lung Cancer Reporting (Resection Specimens) Process CQM Details cqm 397 Melanoma Reporting Process CQM Details cqm 401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Process CQM Details cqm 402 Tobacco Use and Help with Quitting Among Adolescents Process CQM Details cqm 405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions Process CQM Details cqm 406 Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients Process CQM Details cqm 413 Door to Puncture Time for Endovascular Stroke Treatment Process CQM, MVP Details cqm cqm-mvp mvp 415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Process CQM, MVP Details cqm cqm-mvp mvp 419 Overuse of Imaging for the Evaluation of Primary Headache Process CQM, MVP Details cqm cqm-mvp mvp 424 Perioperative Temperature Management Outcome CQM, MVP Details cqm cqm-mvp mvp 430 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy Process CQM, MVP Details cqm cqm-mvp mvp 431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Process CQM, MVP Details cqm cqm-mvp mvp 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) Process CQM, MVP Details cqm cqm-mvp mvp 410 Psoriasis: Clinical Response to Systemic Medications Outcome CQM Details cqm 416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years Process CQM Details cqm 420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey Outcome CQM Details cqm 421 Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal Process CQM Details cqm 422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury Process CQM Details cqm 432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair Outcome CQM Details cqm 433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair Outcome CQM Details cqm 439 Age Appropriate Screening Colonoscopy Process CQM Details cqm 440 Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician Process CQM Details cqm 443 Non-Recommended Cervical Cancer Screening in Adolescent Females Process CQM Details cqm 445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) Outcome CQM Details cqm 448 Appropriate Workup Prior to Endometrial Ablation Process CQM Details cqm 450 Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer Process CQM, MVP Details cqm cqm-mvp mvp 451 RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy Process CQM, MVP Details cqm cqm-mvp mvp 452 Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies Process CQM, MVP Details cqm cqm-mvp mvp 453 Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) Process CQM, MVP Details cqm cqm-mvp mvp 457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) Outcome CQM, MVP Details cqm cqm-mvp mvp 463 Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) Process CQM, MVP Details cqm cqm-mvp mvp 470 Functional Status After Primary Total Knee Replacement Outcome CQM, MVP Details cqm cqm-mvp mvp 477 Multimodal Pain Management Process CQM, MVP Details cqm cqm-mvp mvp 489 Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy Process CQM, MVP Details cqm cqm-mvp mvp 459 Back Pain After Lumbar Surgery Outcome CQM Details cqm 461 Leg Pain After Lumbar Surgery Outcome CQM Details cqm 464 Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use Process CQM Details cqm 465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries Process CQM Details cqm 468 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) Process CQM Details cqm 471 Functional Status After Lumbar Surgery Outcome CQM Details cqm 478 Functional Status Change for Patients with Neck Impairments Outcome CQM Details cqm 486 Dermatitis – Improvement in Patient-Reported Itch Severity Outcome CQM Details cqm 485 Psoriasis – Improvement in Patient-Reported Itch Severity Outcome CQM Details cqm 487 Screening for Social Drivers of Health Process CQM Details cqm 488 Kidney Health Evaluation Process CQM Details cqm cqm-ecqm ecqm 493 Adult Immunization Status Process CQM, MVP Details cqm cqm-mvp mvp 490 Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors Process CQM Details cqm 491 Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma Process CQM Details cqm 024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older Process CQM, MVP Details cqm cqm-mvp mvp 222 Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma Outcome CQM Details cqm 391 Follow-up After Hospitalization for Mental Illness (FUH) Process CQM Details cqm 418 Osteoporosis Management in Women Who Had a Fracture Outcome CQM Details cqm 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Process CQM, eCQM, MVP Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp HM07 Functional Status Change for Patients with Vestibular Dysfunction Outcome QCDR Details qcdr IROMS11 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID Outcome QCDR Details qcdr IROMS12 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with knee injury pain Outcome QCDR Details qcdr IROMS13 Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID Outcome QCDR Details qcdr IROMS14 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury Outcome QCDR Details qcdr IROMS15/KEET01 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI) Outcome QCDR Details qcdr IROMS16 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury Outcome QCDR Details qcdr IROMS17 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score Outcome QCDR Details qcdr IROMS18 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with low back pain Outcome QCDR Details qcdr IROMS19 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID Outcome QCDR Details qcdr IROMS20 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury Outcome QCDR Details qcdr MBHR01 Use of Anxiety Severity Process QCDR Details qcdr MBHR02 Anxiety Response at 6-months Outcome QCDR Details qcdr MBHR03 Pain Interference Response utilizing PROMIS Outcome QCDR Details qcdr MBHR05 Monitoring for psychosocial problems among children and youth Outcome QCDR Details qcdr MBHR07 Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children Outcome QCDR Details qcdr MBHR08 Alcohol Use Disorder Outcome Response Outcome QCDR Details qcdr MBHR09 Outcome monitoring of ADHD functional impairment in children and youth Outcome QCDR Details qcdr MBHR10 Symptom Improvement in adults with ADHD Outcome QCDR Details qcdr MBHR11 Cognitive Assessment with Counseling on Safety and Potential Risk Process QCDR Details qcdr AQI48 Patient-Reported Experience with Anesthesia Outcome QCDR, MVP Details mvp qcdr qcdr-mvp AQI69 Intraoperative Antibiotic Redosing Process QCDR, MVP Details mvp qcdr qcdr-mvp ECPR46 Avoidance of Opiate Prescriptions for Low Back Pain or Migraines Process QCDR, MVP Details mvp qcdr qcdr-mvp MBHR18 Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of Results Process QCDR Details qcdr MBHR13 Social Role Functioning Assessment utilizing PROMIS Adult Ability to Participate in Social Roles and Activities Process QCDR Details qcdr MBHR14 Sleep Quality Sleep Response at 3-months Outcome QCDR Details qcdr MBHR15 Consideration of Cultural-Linguistic and Demographic Factors in Cognitive Assessment Process QCDR Details qcdr MBHR16 Comprehensive Cognitive Assessment Assists with Differential Diagnosis Process QCDR Details qcdr ACEP59 Chest Pain: Avoidance of admission for adult patients with low-risk chest pain Outcome QCDR Details qcdr AQI72 Perioperative Anemia Management Process QCDR Details qcdr AQI73 Prevention of Arterial Line-Related Bloodstream Infections Process QCDR Details qcdr ECPR39 Avoid Head CT for Patients with Uncomplicated Syncope Process QCDR Details qcdr ECPR51 Discharge Prescription of Naloxone after Opioid Poisoning or Overdose Process QCDR Details qcdr ECPR52 Appropriate Treatment of Psychosis and Agitation in the Emergency Department Process QCDR Details qcdr ECPR55 Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain Process QCDR Details qcdr ECPR56 Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment Process QCDR Details qcdr HCPR16 Physicians Orders for Life-Sustaining Treatment (POLST) Process QCDR Details qcdr HCPR17 Pressure Ulcers -Risk Assessment and Plan of Care Process QCDR Details qcdr HCPR20 Clostridium Difficile- Risk Assessment and Plan of Care Process QCDR Details qcdr HCPR23 Avoidance of Echocardiogram and Carotid Ultrasound for Syncope Process QCDR Details qcdr HCPR24 Appropriate Utilization of Vancomycin for Cellulitis Process QCDR Details qcdr 483 Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) Outcome CQM Details cqm 304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery Outcome CQM Details cqm 303 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery Outcome CQM Details cqm 482 Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate Outcome CQM Details cqm 110 Preventive Care and Screening: Influenza Immunization Missing Attachment Process Details cqm cqm-ecqm cqm-ecqm-mvp cqm-mvp mvp 1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Details ecqm mips-cqm-2 5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Details ecqm mips-cqm-2 7 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%) Details ecqm mips-cqm-2 8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Details ecqm mips-cqm-2 19 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Details ecqm mips-cqm-2 65 Appropriate Treatment for Upper Respiratory Infection (URI) Details ecqm mips-cqm-2 66 Appropriate Testing for Pharyngitis Details ecqm mips-cqm-2 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Details ecqm mips-cqm-2 112 Breast Cancer Screening Details ecqm mips-cqm-2 117 Diabetes: Eye Exam Details ecqm mips-cqm-2 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Details ecqm mips-cqm-2 130 Documentation of Current Medications in the Medical Record Details ecqm mips-cqm-2 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan Details ecqm mips-cqm-2 143 Oncology: Medical and Radiation – Pain Intensity Quantified Details ecqm mips-cqm-2 191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Details ecqm mips-cqm-2 205 Sexually Transmitted Infection (STI) Testing for People with HIV Details ecqm mips-cqm-2 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Details ecqm mips-cqm-2 236 Controlling High Blood Pressure Details ecqm mips-cqm-2 238 Use of High-Risk Medications in Older Adults Details ecqm mips-cqm-2 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Details ecqm mips-cqm-2 338 HIV Viral Suppression Details ecqm mips-cqm-2 370 Depression Remission at Twelve Months Details ecqm mips-cqm-2 374 Closing the Referral Loop: Receipt of Specialist Report Details ecqm mips-cqm-2 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Details ecqm mips-cqm-2 488 Kidney Health Evaluation Details ecqm mips-cqm-2 
