2021 Topped Out MIPS Quality Measures: CQMs
These measures are capped at 7 points for the 2021 performance period.
CMS defines a topped-out measure as one whose median performance score is 95% or higher and whose performance is “so high and unvarying that meaningful distinctions and improvement in performance can no longer be made.” CMS has established a 4-year timeline for identifying and removing topped-out measures. If a measure is classified as topped-out for 3 consecutive years, it may be removed the 4th year subject to rule-making and public comment period. In the final rule, CMS has added a new criterion for removing measures identified as “extremely topped-out,” that is, measures with an average performance within the 98th to 100th percentile. For these measures, regardless of where they are in the topped out measure lifecycle, CMS may propose to remove them in the following year’s rulemaking cycle. These measures may not follow the 4-year lifecycle that is applicable to other measures.
| Quality Id | Measure Name | Measure Type | Measure Description | hf:tax:specialty_measure_sets | hf:tax:collection_types | |
|---|---|---|---|---|---|---|
| 014 | Age-Related Macular Degeneration (AMD): Dilated Macular Examination | Process | Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period | Details | ||
| 019 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months | Details | ||
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin | Process | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis | Details | ||
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | Process | Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Details | ||
| 044 | Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | Process | Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision | Details | ||
| 052 | Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | Process | Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator | Details | ||
| 065 | Appropriate Treatment for Children with Upper Respiratory Infection (URI) | Process | Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode | Details | ||
| 008 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Process | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge | Details | ||
| 130 | Documentation of Current Medications in the Medical Record | Process | Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration | Details | ||
| 138 | Melanoma: Coordination of Care | Process | Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis | Details | ||
| 117 | Diabetes: Eye Exam | Process | Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period. | Details | ||
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | Process | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer | Details | ||
| 093 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | Process | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Details | ||
| 076 | Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | Process | Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed | Details | ||
| 143 | Oncology: Medical and Radiation – Pain Intensity Quantified | Process | Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified. | Details | ||
| 145 | Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | Process | Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available) | Details | ||
| 147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | Process | Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed | Details | ||
| 154 | Falls: Risk Assessment | Process | Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months | Details | ||
| 178 | Rheumatoid Arthritis (RA): Functional Status Assessment | Process | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months. | Details | ||
| 185 | Colonoscopy Interval for Patients with a History of Adenomatous Polyps– Avoidance of Inappropriate Use | Process | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy | Details | ||
| 187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy | Process | Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well | Details | ||
| 191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | Outcome | Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery. | Details | ||
| 195 | Radiology: Stenosis Measurement in Carotid Imaging Reports | Process | Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement | Details | ||
| 265 | Biopsy Follow-Up | Process | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient | Details | ||
| 264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer | Process | The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure | Details | ||
| 250 | Radical Prostatectomy Pathology Reporting | Process | Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status | Details | ||
| 249 | Barrett’s Esophagus | Process | Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia | Details | ||
| 254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | Process | Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location | Details | ||
| 279 | Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | Process | Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured | Details | ||
| 282 | Dementia: Functional Status Assessment | Process | Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months | Details | ||
| 283 | Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | Process | Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months | Details | ||
| 286 | Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | Process | Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources | Details | ||
| 291 | Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease | Process | Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 months | Details | ||
| 293 | Parkinson’s Disease: Rehabilitative Therapy Options | Process | Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 months | Details | ||
| 320 | Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | Process | Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Details | ||
| 326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | Process | Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period | Details | ||
| 332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | Process | Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis | Details | ||
| 360 | Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | Process | Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study | Details | ||
| 384 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | Outcome | Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery | Details | ||
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Process | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Details | ||
| 358 | Patient-Centered Surgical Risk Assessment and Communication | Process | Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon | Details | ||
| 351 | Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | Process | Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke) | Details | ||
| 350 | Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | Process | Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure | Details | ||
| 395 | Lung Cancer Reporting (Biopsy/Cytology Specimens) | Process | Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report | Details | ||
| 396 | Lung Cancer Reporting (Resection Specimens) | Process | Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type | Details | ||
| 397 | Melanoma Reporting | Process | Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate | Details | ||
| 402 | Tobacco Use and Help with Quitting Among Adolescents | Process | The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user | Details | ||
| 424 | Perioperative Temperature Management | Outcome | Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time | Details | ||
| 425 | Photodocumentation of Cecal Intubation | Process | The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination | Details | ||
| 430 | Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | Process | Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively | Details | ||
| 436 | Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | Process | Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique | Details | ||
| 440 | Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician | Process | Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist | Details | ||
| 444 | Medication Management for People with Asthma | Process | The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period | Details | ||
| 463 | Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) | Process | Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively | Details | ||
| 464 | Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | Process | Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials | Details |