CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.
| Quality Id | Measure Name | High Priority | Measure Type | Measure Description | hf:tax:specialty_measure_sets | hf:tax:collection_types | |
|---|---|---|---|---|---|---|---|
| 375 | 2022 MIPS Measure #375: Functional Status Assessment for Total Knee Replacement | eCQM | Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery | Details | |||
| 318 | 2022 MIPS Measure # 318: Falls: Screening for Future Fall Risk | eCQM | Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period | Details | |||
| 376 | 2022 MIPS Measure #376: Functional Status Assessment for Total Hip Replacement | eCQM | Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery | Details | |||
| 024 | 2022 Measure # 024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | yes | Process | Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | Details | ||
| 047 | 2022 Measure # 047 Advance Care Plan | yes | Process | 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 | Details | ||
| 128 | 2022 Measure # 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | no | 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 | Details | ||
| 130 | 2022 Measure # 130 Documentation of Current Medications in the Medical Record | yes | 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 | ||
| 134 | 2022 Measure # 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan | no | Process | Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 14 days prior to 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 eligible encounter | Details | ||
| 155 | 2022 Measure # 155 Falls: Plan of Care | yes | Process | 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 | Details | ||
| 222 | 2022 Measure # 222 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | yes | Patient Reported Outcome | Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | Details | ||
| 226 | 2022 Measure # 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | no | Process | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user | Details | ||
| 221 | 2022 Measure # 221 Functional Status Change for Patients with Shoulder Impairments | yes | Patient Reported Outcome | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the FOTO Shoulder FS patient-reported outcome measure (PROM). The 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 level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure) | Details | ||
| 220 | 2022 Measure # 220 Functional Status Change for Patients with Low Back Impairments | yes | Patient Reported Outcome | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the FOTO Low Back FS patient-reported outcome measure (PROM). The 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 level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure). | Details | ||
| 218 | 2022 Measure # 218 Functional Status Change for Patients with Hip Impairments | yes | Patient Reported Outcome | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM) . The 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 level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure). | Details | ||
| 182 | 2022 Measure # 182 Functional Outcome Assessment | yes | Process | 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. | Details | ||
| 180 | 2022 Measure # 180 Rheumatoid Arthritis (RA): Glucocorticoid Management | no | 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 | ||
| 178 | 2022 Measure # 178 Rheumatoid Arthritis (RA): Functional Status Assessment | no | 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 | ||
| 219 | 2022 Measure # 219 Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | yes | Patient Reported Outcome | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle or lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient- reported outcome measure (PROM). The 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 level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure). | Details | ||
| 350 | 2022 Measure # 350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | yes | Process | Percentage of patients regardless of age undergoing a total knee or total hip 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. | Details | ||
| 351 | 2022 Measure # 351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | yes | Process | Percentage of patients regardless of age undergoing a total knee or total hip 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 | ||
| 358 | 2022 Measure # 358 Patient-Centered Surgical Risk Assessment and Communication | yes | 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 | ||
| 374 | 2022 Measure # 374 Closing the Referral Loop: Receipt of Specialist Report | yes | 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 | ||
| 402 | 2022 Measure # 402 Tobacco Use and Help with Quitting Among Adolescents | no | 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 | ||
| 418 | 2022 Measure # 418 Osteoporosis Management in Women Who Had a Fracture | no | Process | The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period 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 | Details | ||
| 459 | 2022 Measure # 459 Back Pain After Lumbar Discectomy/Laminotomy | yes | Patient Reported Outcome | For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively. | Details | ||
| 460 | 2022 Measure # 460 Back Pain After Lumbar Fusion | yes | Patient Reported Outcome | For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively * hereafter referred to as VAS Pain. | Details | ||
| 461 | 2022 Measure # 461 Leg Pain After Lumbar Discectomy/ Laminotomy | yes | Patient Reported Outcome | For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively | Details | ||
| 469 | 2022 Measure # 469 Functional Status After Lumbar Fusion | yes | Patient Reported Outcome | For patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a)* at one year (9 to 15 months) postoperatively. * hereafter referred to as ODI | Details | ||
| 470 | 2022 Measure # 470 Functional Status After Primary Total Knee Replacement | yes | Patient Reported Outcome | For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR. tool at one year (9 to 15 months) postoperatively | Details | ||
| 471 | 2022 Measure # 471 Functional Status After Lumbar Discectomy/Laminectomy | yes | Patient Reported Outcome | For patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively. * hereafter referred to as ODI | Details | ||
| 473 | 2022 Measure # 473 Leg Pain After Lumbar Fusion | yes | Patient Reported Outcome | For patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively * hereafter referred to as VAS Pain. | Details | ||
| 478 | 2022 Measure # 478 Functional Status Change for Patients with Neck Impairments | yes | Patient Reported Outcome | A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient-reported outcome measure (PROM). The 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 level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paper-pencil). | Details |
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