2021 NON Telehealth-Related Quality Measures: CQMs
With the advent of COVID-19 pandemic outbreak, we recognize that a significant amount of healthcare is now being delivered via telehealth. Identifying those measures which are NOT relevant to telehealth will help many providers limit the amount of reporting done for MIPS in 2021.
| Quality Id | Measure Name | Measure Type | Measure Description | hf:tax:specialty_measure_sets | hf:tax:collection_types | |
|---|---|---|---|---|---|---|
| 006 | Coronary Artery Disease (CAD): Antiplatelet Therapy | Process | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel | Details | ||
| 007 | Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | Process | Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy. | 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 | ||
| 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 | ||
| 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 | ||
| 067 | Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | Process | Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow | Details | ||
| 070 | Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | Process | Percentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart | Details | ||
| 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 | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge | Details | ||
| 128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | Process | Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2 | Details | ||
| 141 | Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | Outcome | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period | 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 | ||
| 137 | Melanoma: Continuity of Care – Recall System | Structure | Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment | Details | ||
| 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing | Details | ||
| 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months | Details | ||
| 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 | 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 | Details | ||
| 110 | Preventive Care and Screening: Influenza Immunization | Process | Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization | 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 | ||
| 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 | ||
| 144 | Oncology: Medical and Radiation – Plan of Care for Moderate to Severe Pain | Process | Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician | Details | ||
| 176 | Rheumatoid Arthritis (RA): Tuberculosis Screening | Process | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who havedocumentation of a tuberculosis (TB) screening performed and results interpreted within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD) | Details | ||
| 177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | Process | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity at ≥50% of encounters for RA for each patient during the measurement year | 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 | ||
| 180 | Rheumatoid Arthritis (RA): Glucocorticoid Management | Process | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months. | Details | ||
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Process | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen | 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 | ||
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Process | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. | 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 | ||
| 243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | Process | Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program | Details | ||
| 268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | Process | 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 | 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 | ||
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | Process | Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms | 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 | ||
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Process | Percentage of patients aged 18 years and older seen during the 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 | 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 | ||
| 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 | ||
| 290 | Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease | Process | Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms in the past 12 months | Details | ||
| 288 | Dementia: Education and Support of Caregivers for Patients with Dementia | Process | Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months | 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 277 | Sleep Apnea: Severity Assessment at Initial Diagnosis | Process | Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis | Details | ||
| 337 | Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier | Process | Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test | Details | ||
| 386 | Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | Process | Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually | Details | ||
| 387 | Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | Process | Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period | Details | ||
| 400 | One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | Process | Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection | Details | ||
| 410 | Psoriasis: Clinical Response to Systemic Medications | Outcome | Percentage of psoriasis vulgaris patients receiving systemic 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 | Details | ||
| 419 | Overuse of Imaging for the Evaluation of Primary Headache | Process | Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present | Details | ||
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | Process | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user | Details | ||
| 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | Process | Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the performance period. | 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 |