| 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 |
| 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 |
| 475 | 2022 MIPS Measure #475: HIV Screening | | eCQM | Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV | Details |
| 476 | 2022 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia | | eCQM | Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points | Details |
| 239 | 2022 MIPS Measure #239: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | | eCQM | Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. | Details |
| 309 | 2022 MIPS Measure #309: Cervical Cancer Screening | | eCQM | Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: | Details |
| 310 | 2022 MIPS Measure #310: Chlamydia Screening for Women | | eCQM | Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period | Details |
| 305 | 2022 MIPS Measure #305: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | | eCQM | Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported. | Details |
| 462 | 2022 MIPS Measure # 462: Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy | | eCQM | Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT. | Details |
| 107 | 2022 MIPS Measure #107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | | eCQM | All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit | 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 |
| 378 | 2022 MIPS Measure #378: Children Who Have Dental Decay or Cavities | | eCQM | Percentage of children, 6 months - 20 years of age at the start of the measurement period, who have had tooth decay or cavities during the measurement period | Details |
| 379 | 2022 MIPS Measure #379: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | | eCQM | Percentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement period | Details |
| 382 | 2022 MIPS Measure #382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | | eCQM | Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk | Details |
| 281 | 2022 MIPS Measure #281: Dementia: Cognitive Assessment | | eCQM | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period | Details |
| 472 | 2022 MIPS Measure #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | | eCQM | Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period | Details |
| 366 | 2022 MIPS Measure #366: Follow-Up Care for Children Prescribed ADHD Medication (ADD) | | eCQM | Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. | Details |
| HM09 | 2022 HM9: Functional Benefit of a Cochlear Implant | YES | Patient Reported Outcome (PRO) | Percentage of patients aged 18 years and older, who are evaluated for hearing loss and complete a hearing loss self-assessment tool that indicated an impact of hearing-related quality of life (QoL), and if diagnosed with a bilateral moderate to profound sensorineural hearing loss (SNHL) and less than 60% open set speech recognition are scheduled or referred for cochlear implant candidacy testing AND for patients who undergo cochlear implantation, demonstrate a meaningful clinically important difference (MCID) improvement in self-assessment of Hearing-related QoL or an improvement in speech recognition within 18 months of cochlear implant activation. | Details |
| HM10 | 2022 HM10: Outcomes of Hearing Loss Treatment | YES | Patient Reported Outcome (PRO) | Percentage of patients aged 50 years and older, who are screened with a hearing loss self-assessment tool that indicated an impact on hearing-related QoL AND if diagnosed with a mild or greater hearing loss in at least one ear or identified with a hearing loss, receive an audiologic care plan and hearing loss intervention(s) AND report a meaningful clinically important difference (MCID) improvement in hearing-related quality of life (QoL) within 12 months of hearing loss diagnosis. | Details |
| HM11 | 2022 HM11: Outcomes of Treatment of Subjective Tinnitus | YES | Patient Reported Outcome (PRO) | Percentage of patients aged 18 years and older who are screened for bothersome subjective tinnitus AND, if patient reports symptoms, assessed with clinical evaluation for tinnitus severity and impact on hearing-related quality of life (HRQoL) using a validated self-assessment tool AND, if identified with tinnitus that impacts the patients HRQoL, receive a tinnitus-related care plan, and tinnitus-related intervention(s), treatment(s), or management AND who report a meaningful clinically important difference (MCID) improvement in the impact of tinnitus on the patient’s HRQoL within 12 months of initial identification. | Details |
| HM12 | 2022 HM12: Outcomes of Treatment of Benign Paroxysmal Positional Vertigo | YES | Patient Reported Outcome (PRO) | Percentage of patients aged 18 years and older, who report benign paroxysmal positional vertigo (BPPV)-related symptoms and are screened with a dizziness assessment questionnaire and undergo positional nystagmus testing AND, if diagnosed or identified with BPPV, received a BPPV-related care plan and vestibular intervention(s) or treatment(s) AND who have an improvement in nystagmus or report an improvement in BPPV-related symptoms, and report a meaningful clinically important difference (MCID) improvement of BPPV-related quality of life (QoL). | Details |
| IROMS11 | 2022 QCDR Measure: 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 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 | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported. | Details |
| IROMS12 | 2022 QCDR Measure: 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 of patients with knee injury | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with knee injury treated during the observation period will be reported. | Details |
| IROMS13 | 2022 QCDR Measure: 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 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 | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. | Details |
| IROMS14 | 2022 QCDR Measure: 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 of patients with hip, leg, or ankle (lower extremity except knee) injury | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injury treated during the observation period will be reported. | Details |
| IROMS15 | 2022 QCDR Measure: 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 their validated Neck Disability Index (NDI) score | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of seven and ½ (7.5) points or more improvement in the NDI change score for patients with neck pain/injury treated during the observation period will be reported. | Details |
| IROMS16 | 2022 QCDR Measure: 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 of patients with neck pain/injury | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported. | Details |
| IROMS17 | 2022 QCDR Measure: 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 low back pain measured via their validated Modified Low Back Pain Disability Questionnaire (MDQ) score | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. | Details |
| IROMS18 | 2022 QCDR Measure: 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 of patients with low back pain | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported. | Details |
| IROMS19 | 2022 QCDR Measure: 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, or hand injury measured via their validated Disability of the Arm, Shoulder and Hand (DASH) score, Quick Disability of the Arm, Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder or hand injury treated during the observation period will be reported. | Details |
| IROMS20 | 2022 QCDR Measure: 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 of patients with arm, shoulder, or hand injury | YES | Patient Reported Outcome | The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported. | Details |
| HM07 | 2022 QCDR Measure: Functional Status Change for Patients with Vestibular Dysfunction | YES | Patient Reported Outcome | Percentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) to indicate functional, emotional, and physical improvement. | Details |
| MBHR01 | Use of Anxiety Severity Measure | No | Process | The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, BAI) during measurement period. | Details |
| MBHR02 | Anxiety Response at 6-months | Yes | Patient Reported Outcome (PRO) | The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment (GAD-7 score at least 25% less than score at index event) at 6-months (+/- 60 days) after an index visit. | Details |
| MBHR03 | Pain Interference Response utilizing PROMIS | Yes | Patient Reported Outcome (PRO) | The percentage of adult patients (18 years of age or older) who report chronic pain issues and demonstrated a response to treatment at one month from the index score. | Details |
| MBHR05 | Monitoring for psychosocial problems among children and youth | Yes | Patient Reported Outcome (PRO) | Percentage of children from 3 to 17 years of age who are receiving a psychiatric or behavioral health intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 10 months after initial positive screen for externalizing and internalizing behavior problems. | Details |
| MBHR07 | Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children | Yes | Patient Reported Outcome (PRO) | The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event AND with documentation of a standardized symptom monitor (PCL-5 for adults, CATS for child/adolescent) AND demonstrated a response to treatment at six months (+/- 120 days) after the index visit.
This measure is a multi-strata measure, which addresses symptom monitoring for both child and adult patients being treated for post-traumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different. | Details |
| MBHR08 | Alcohol Use Disorder Outcome Response | Yes | Patient Reported Outcome (PRO) | The percentage of adult patients (18 years of age or older) who report problems with drinking alcohol (e.g., can be noted through a screening measure such as the AUDIT-C as described in MIPS Clinical Quality Measure Quality ID #431 aka NQF 2152 or other drug/alcohol screeners such as the DAST and TAPS AND demonstrated a response to treatment at three months (+/- 60 days) after the index visit. | Details |
| MBHR09 | Outcome monitoring of ADHD functional impairment in children and youth | Yes | Patient Reported Outcome (PRO) | Percentage of children aged 4 through 18 years, with a diagnosis of attention deficit/hyperactivity disorder (ADHD), who demonstrate a change score of 0.25 or greater on the Weiss Functional Impairment Rating Scale - Parent Report (WFIRS-P) within 2 to 10 months after an initial positive finding of functional impairment. | Details |
| MBHR10 | Symptom Improvement in adults with ADHD | Yes | Patient Reported Outcome (PRO) | The percentage of adult patients (18 years of age or older) with a diagnosis of ADHD who show a reduction in symptoms of 25% on the Adult ADHD Self-Report Scale (ASRS-v1.1)- 18 item self-report scale of ADHD symptoms within 2 to 10 months after initially reporting significant symptoms.
There are two aspects to this measure. The first is the assessment of the use of the ASRS v.1. during the denominator identification period (Criteria 1 also referred to as Time 1) and the second is the assessment of improvement in the ASRS v.1.1 from the first administration to the second administration of the ASRS v.1.1 (Criteria 2 also referred to as Time 2). | Details |
| MBHR11 | Cognitive Assessment with Counseling on Safety and Potential Risk | No | Process | Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) reporting of results included counseling on safety and potential risks. | Details |
| MBHR12 | Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan | Yes | Process | Percentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback regarding test results and associated recommendations, who acknowledged understanding of test results and associated recommendations and healthcare plan. | Details |
| MBHR13 | Social Role Functioning Assessment utilizing PROMIS Adult Ability to Participate in Social Roles and Activities | Yes | Patient Reported Outcome (PRO) | The percentage of adult patients (18 years of age or older) who report concerns related to their psychosocial function and who have completed a standardized assessment utilizing the PROMIS Adult Ability to Participate in Social Roles and Activities during measurement period | Details |
| MBHR14 | Sleep Quality Response at 3-months | Yes | Patient Reported Outcome (PRO) | Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool AND demonstrated a response to treatment at three months (+/- 60 days) after index visit. | Details |
| MBHR15 | Consideration of Cultural-Linguistic and Demographic Factors in Cognitive Assessment | Yes | Process | Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive changes or difficulties for whom 1) a standardized valid assessment of cognition was performed and 2) interpretation of results included consideration of appropriate and relevant cultural-linguistic and demographic factors. | Details |
| MBHR16 | Comprehensive Cognitive Assessment Assists with Differential Diagnosis | Yes | Process | Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) results of assessment informed determination of diagnosis or further clarified etiological factors of cognitive impairment or complaints. | Details |
| MBHR17 | Improved Efficiency: Time Interval for reporting results of cognitive assessment | Yes | Process | Percentage of patients, regardless of age, for which the referring provider or patient receives reporting of assessment results within 14 days of the completion of assessment. | Details |
| ACEP19 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | Yes | Process | Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT | Details |
| ACEP50 | ED Median Time from ED arrival to ED departure for all Adult Patients | Yes | Outcome | Time (in minutes) from ED arrival to ED departure for all Adult Patients | Details |
| ACQR12 | ABCDEF Bundle - Early mobility for ICU patients | Yes | Process | Patients admitted to the intensive care unit (ICU) for > or = 4 days should be included in an early mobility program (E of ABCDEF Bundle) to improve their recovery process. | Details |
| ACQR13 | Sepsis: Hour One bundle | No | Process | Surviving Sepsis Campaign's Hour One bundle initiation in patients with Sepsis and acute organ dysfunction | Details |
| ACQR16 | COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation | Yes | Efficiency and Cost/Resource Use | Patients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapnic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available; and patients admitted with AHA Class D heart failure and/or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available | Details |
| AQI69 | Intraoperative Antibiotic Redosing | Yes | Process | Percentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision (if fluoroquinolone or vancomycin, two hours) and undergo a procedure greater than two hours duration who received intraoperative antibiotic redosing at a maximum interval of two half-lives of the selected prophylactic antibiotic. | Details |
| AQI73 | Prevention of Arterial Line-Related Bloodstream Infections | Yes | Process | Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial catheter for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
This measure will consist of three performance rates:
a. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the brachial, radial, posterior tibial or dorsalis pedis artery for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
b. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the femoral or axillary artery for whom the arterial line was inserted with all indicated elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound technique is followed
Note: The overall measure score will be calculated as an average of the total cases of part A (rate 2) and part B (rate 3). The overall measure score is rate 1. | Details |
| AQI72 | Perioperative Anemia Management | Yes | Process | Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge.
Management strategies include one or more of the following:
• Cell salvage techniques employed intraoperatively
• Intraoperative antifibrinolytic therapy or tourniquet, if not contraindicated
• Preoperative iron supplementation, epoetin alpha
• Use of evidence-based preoperative anemia management algorithm supplemented with laboratory testing and/or multidisciplinary consult | Details |
| ECPR39 | Avoid Head CT for Patients with Uncomplicated Syncope | Yes | Process | Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider | Details |
| ECPR41 | Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure | No | Process | Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative | Details |
| ECPR46 | Avoidance of Opiates for Low Back Pain or Migraines | Yes | Process | Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate | Details |
| ECPR51 | Discharge Prescription of Naloxone after Opioid Poisoning or Overdose | Yes | Process | Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge | Details |
| ECPR52 | Appropriate Treatment of Psychosis and Agitation in the Emergency Department | No | Process | Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department | Details |
| ECPR57 | Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor Vehicles | Yes | Process | Percentage of Patients At Risk for Recurrent Loss of Consciousness For Whom Loss of Consciousness Information Was Submitted to Department of Public Health or Department of Motor Vehicles | Details |
| ECPR55 | Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain | Yes | Process | Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation and for Whom the Prescription Duration Was Not Greater than 3 days for Acute Pain | Details |
| ECPR56 | Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment | Yes | Process | Percentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication-Assisted Treatment and Referred to Outpatient Opioid Treatment | Details |
| HCPR14 | Venous Thromboembolism (VTE) Prophylaxis | Yes | Process | Percentage of Adult Patients Who Had VTE Prophylaxis Ordered at the Time of Admission OR Have Documentation of Reason for No VTE Prophylaxis | Details |
| HCPR16 | Physician’s Orders for Life-Sustaining Treatment (POLST) Form | Yes | Process | Percentage of Patients Greater Than or Equal to 65 Years of Age with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed | Details |
| HCPR17 | Pressure Ulcers – Risk Assessment and Plan of Care | Yes | Process | Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed | Details |
| HCPR18 | Unintentional Weight Loss – Risk Assessment and Plan of Care | Yes | Process | Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider | Details |
| HCPR23 | Avoidance of Echocardiogram and Carotid Ultrasound for Syncope | Yes | Process | Percentage of Patients Presenting with Syncope Who Did Not Have an Echocardiogram or Carotid Ultrasound Ordered | Details |
| HCPR24 | Appropriate Utilization of Vancomycin for Cellulitis | Yes | Process | Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified | Details |
| ACEP59 | Chest Pain – Avoidance of admission for adult patients with low-risk chest pain. | Yes | Outcome | Percentage of adult patients who came to the Emergency Department with low-risk chest pain and were discharged | Details |
| ACEP61 | Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup | Yes | Process | Percentage of ED visits for pediatric patients with Asthma, Bronchiolitis or Croup for whom a Chest X-ray was ordered/performed. | Details |
| 001 | 2022 Measure # 001 Diabetes: Hemoglobin A1c Poor Control | yes | Intermediate Outcome | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. | Details |
| 005 | 2022 Measure # 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) | no | 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 |
| 006 | 2022 Measure # 006 Coronary Artery Disease (CAD): Antiplatelet Therapy | no | 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 | 2022 Measure # 007 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | no | 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 | 2022 Measure # 008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | no | 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 | 2022 Measure # 014 Age-Related Macular Degeneration (AMD): Dilated Macular Examination | no | 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 | 2022 Measure # 019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | yes | 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 |
| 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 |
| 039 | 2022 Measure # 039 Screening for Osteoporosis for Women Aged 65-85 Years of Age | no | Process | Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis | 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 |
| 048 | 2022 Measure # 048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | no | Process | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Details |
| 050 | 2022 Measure # 050 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | yes | Process | Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months | Details |
| 052 | 2022 Measure # 052 Chronic Obstructive Pulmonary Disease (COPD) Long-Acting Inhaled Bronchodilator Therapy | no | 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 an long-acting inhaled bronchodilator | Details |
| 065 | 2022 Measure # 065 Appropriate Treatment for Upper Respiratory Infection (URI) | yes | Process | Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event | Details |
| 066 | 2022 Measure # 066 Appropriate Testing for Pharyngitis | yes | Process | The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test | Details |
| 076 | 2022 Measure # 076 Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections | yes | 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 |
| 093 | 2022 Measure # 093 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | yes | Process | Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy | Details |
| 102 | 2022 Measure # 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | yes | 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 who did not have a bone scan performed at any time since diagnosis of prostate cancer | Details |
| 104 | 2022 Measure # 104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | no | Process | Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate | Details |
| 110 | 2022 Measure # 110 Preventive Care and Screening: Influenza Immunization | no | 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 |
| 126 | 2022 Measure # 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | no | 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 |
| 127 | 2022 Measure # 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | no | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing | 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 |
| 111 | 2022 Measure # 111 Pneumococcal Vaccination Status for Older Adults | no | Process | Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine | Details |
| 112 | 2022 Measure # 112 Breast Cancer Screening | no | Process | Percentage of women 50 – 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period. | Details |
| 113 | 2022 Measure # 113 Colorectal Cancer Screening | no | Process | Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer. | Details |
| 116 | 2022 Measure # 116 Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | yes | Process | The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription | Details |
| 117 | 2022 Measure # 117 Diabetes: Eye Exam | no | Process | Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of 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 in any part of 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 |
| 118 | 2022 Measure # 118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | no | 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 |
| 119 | 2022 Measure # 119 Diabetes: Medical Attention for Nephropathy | no | Process | The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period. | Details |
| 137 | 2022 Measure # 137 Melanoma: Continuity of Care – Recall System | yes | 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: | Details |
| 138 | 2022 Measure # 138 Melanoma: Coordination of Care | yes | 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 |
| 141 | 2022 Measure # 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | yes | 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 |
| 143 | 2022 Measure # 143 Oncology: Medical and Radiation – Pain Intensity Quantified | yes | 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 | 2022 Measure # 144 Oncology: Medical and Radiation – Plan of Care for Pain | yes | Process | Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain | Details |
| 145 | 2022 Measure # 145 Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | yes | 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 | 2022 Measure # 147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | yes | 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, MRI, CT, etc.) that were performed | Details |
| 181 | 2022 Measure # 181 Elder Maltreatment Screen and Follow-Up Plan | yes | 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 |
| 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 |
| 164 | 2022 Measure # 164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation | no | Process | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours. | Details |
| 167 | 2022 Measure # 167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | no | Process | Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis. | Details |
| 168 | 2022 Measure # 168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | no | Process | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason. | Details |
| 176 | 2022 Measure # 176 Tuberculosis Screening Prior to First Course Biologic Therapy | no | Process | If a patient has been newly prescribed a biologic disease-modifying anti-rheumatic drug (DMARD) therapy, then the medical record should indicate TB testing in the preceding 12-month period. | Details |
| 177 | 2022 Measure # 177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | no | Process | Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the measurement year | 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 |
| 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 |
| 185 | 2022 Measure # 185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | no | Process | Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy. | Details |
| 187 | 2022 Measure # 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy | no | 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 | 2022 Measure # 191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | yes | 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 |
| 205 | 2022 Measure # 205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | no | Process | Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection | Details |
| 217 | 2022 Measure # 217 Functional Status Change for Patients with Knee Impairments | yes | Patient Reported Outcome | A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 236 | 2022 Measure # 236 Controlling High Blood Pressure | yes | Intermediate Outcome | Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period | Details |
| 238 | 2022 Measure # 238 Use of High-Risk Medications in Older Adults | yes | Process | Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class | Details |
| 243 | 2022 Measure # 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting | yes | 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 |
| 249 | 2022 Measure # 249 Barrett's Esophagus | no | Process | Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia | Details |
| 250 | 2022 Measure # 250 Radical Prostatectomy Pathology Reporting | no | 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 |
| 254 | 2022 Measure # 254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | no | 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 |
| 258 | 2022 Measure # 258 Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | yes | Outcome | Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) | Details |
| 259 | 2022 Measure # 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) | yes | Outcome | Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) | Details |
| 260 | 2022 Measure # 260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | yes | Outcome | Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 | Details |
| 261 | 2022 Measure # 261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | yes | Process | Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness. | Details |
| 264 | 2022 Measure # 264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer | no | 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 |
| 265 | 2022 Measure # 265 Biopsy Follow-Up | yes | Process | Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient. | Details |
| 268 | 2022 Measure # 268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | no | Process | Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy | Details |
| 275 | 2022 Measure # 275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | no | Process | Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy | Details |
| 277 | 2022 Measure # 277 Sleep Apnea: Severity Assessment at Initial Diagnosis | no | 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 |
| 279 | 2022 Measure # 279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | no | 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 | 2022 Measure # 282 Dementia: Functional Status Assessment | no | 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 | 2022 Measure # 283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | no | 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 | 2022 Measure # 286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | yes | 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 |
| 288 | 2022 Measure # 288 Dementia: Education and Support of Caregivers for Patients with Dementia | yes | 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 |
| 290 | 2022 Measure # 290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease | no | Process | Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for depression, anxiety, apathy, AND psychosis once during the measurement period. | Details |
| 291 | 2022 Measure # 291 Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease | no | Process | Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period. | Details |
| 293 | 2022 Measure # 293 Rehabilitative Therapy Referral for Patients with Parkinson’s Disease | yes | Process | Percentage of all patients with a diagnosis of Parkinson’s Disease who were referred to physical, occupational, speech, or recreational therapy once during the measurement period. | Details |
| 317 | 2022 Measure # 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | no | Process | Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive. | Details |
| 320 | 2022 Measure # 320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | yes | Process | Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report | Details |
| 322 | 2022 Measure # 322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | yes | Efficiency | Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period | Details |
| 323 | 2022 Measure # 323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | yes | Efficiency | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status | Details |
| 324 | 2022 Measure # 324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | yes | Efficiency | Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment | Details |
| 326 | 2022 Measure # 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | no | Process | Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed | Details |
| 331 | 2022 Measure # 331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | yes | 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 |
| 332 | 2022 Measure # 332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | yes | 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 |
| 335 | 2022 Measure # 335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) | yes | Outcome | Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor. | Details |
| 336 | 2022 Measure # 336 Maternity Care: Postpartum Follow-Up and Care Coordination | yes | Process | Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update | Details |
| 338 | 2022 Measure # 338 HIV Viral Load Suppression | yes | Outcome | The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year | Details |
| 340 | 2022 Measure # 340 HIV Medical Visit Frequency | yes | Process | Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits | Details |
| 344 | 2022 Measure # 344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | yes | Outcome | Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 | 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 |
| 354 | 2022 Measure # 354 Anastomotic Leak Intervention | yes | Outcome | Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery | Details |
| 355 | 2022 Measure # 355 Unplanned Reoperation within the 30 Day Postoperative Period | yes | Outcome | Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period | Details |
| 356 | 2022 Measure # 356 Unplanned Hospital Readmission within 30 Days of Principal Procedure | yes | Outcome | Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure | Details |
| 357 | 2022 Measure # 357 Surgical Site Infection (SSI) | yes | Outcome | Percentage of patients aged 18 years and older who had a surgical site infection (SSI) | 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 |
| 360 | 2022 Measure # 360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | yes | 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 |
| 364 | 2022 Measure # 364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 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 |
| 370 | 2022 Measure # 370 Depression Remission at Twelve Months | yes | Outcome | The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date. | 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 |
| 383 | 2022 Measure # 383 Adherence to Antipsychotic Medications for Individuals with Schizophrenia | yes | Intermediate Outcome | Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period | Details |
| 384 | 2022 Measure # 384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | yes | 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 |
| 385 | 2022 Measure # 385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | yes | Outcome | Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye | Details |
| 386 | 2022 Measure # 386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | yes | 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 | 2022 Measure # 387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | no | 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 |
| 389 | 2022 Measure # 389 Cataract Surgery: Difference Between Planned and Final Refraction | yes | Outcome | Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction | Details |
| 391 | 2022 Measure # 391 Follow-up After Hospitalization for Mental Illness (FUH) | yes | Process | The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. | Details |
| 392 | 2022 Measure # 392 HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | yes | Outcome | Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender | Details |
| 393 | 2022 Measure # 393 HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | yes | Outcome | Infection rate following CIED device implantation, replacement, or revision | Details |
| 394 | 2022 Measure # 394 Immunizations for Adolescents | no | Process | The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. | Details |
| 395 | 2022 Measure # 395 Lung Cancer Reporting (Biopsy/Cytology Specimens) | yes | Process | Pathology reports based on lung biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type following the International Association for the Study of Lung Cancer (IASLC) guidance or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report. | Details |
| 396 | 2022 Measure # 396 Lung Cancer Reporting (Resection Specimens) | yes | Process | Pathology reports based on lung resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type. | Details |
| 397 | 2022 Measure # 397 Melanoma Reporting | yes | Process | Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors. | Details |
| 398 | 2022 Measure # 398 Optimal Asthma Control | yes | Outcome | Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation | Details |
| 400 | 2022 Measure # 400 One-Time Screening for Hepatitis C Virus (HCV) for all Patients | no | 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 |
| 401 | 2022 Measure # 401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | no | Process | Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period | 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 |
| 404 | 2022 Measure # 404 Anesthesiology Smoking Abstinence | yes | Intermediate Outcome | The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure | Details |
| 405 | 2022 Measure # 405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions | yes | Process | Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow‐up imaging recommended based on radiological findings:
• Cystic renal lesion that is simple appearing* (Bosniak I or II)
• Adrenal lesion less than or equal to 1.0 cm
• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols | Details |
| 406 | 2022 Measure # 406 Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients | yes | Process | Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended | Details |
| 409 | 2022 Measure # 409 Clinical Outcome Post-Endovascular Stroke Treatment | yes | Outcome | Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention. | Details |
| 410 | 2022 Measure # 410 Psoriasis: Clinical Response to Systemic Medications | yes | Outcome | Percentage of psoriasis vulgaris patients receiving systemic medication 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 |
| 413 | 2022 Measure # 413 Door to Puncture Time for Endovascular Stroke Treatment | yes | Intermediate Outcome | Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less. | Details |
| 415 | 2022 Measure # 415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | yes | Efficiency | Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care clinician who have an indication for a head CT | Details |
| 416 | 2022 Measure # 416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years | yes | Efficiency | Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury | 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 |
| 419 | 2022 Measure # 419 Overuse of Imaging for the Evaluation of Primary Headache | yes | 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 |
| 420 | 2022 Measure # 420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | yes | Patient Reported Outcome | Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment | Details |
| 421 | 2022 Measure # 421 Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal | no | Process | Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts | Details |
| 422 | 2022 Measure # 422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | yes | Process | Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse | Details |
| 424 | 2022 Measure # 424 Perioperative Temperature Management | yes | 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 | 2022 Measure # 425 Photodocumentation of Cecal Intubation | no | 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 | 2022 Measure # 430 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | yes | 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 or intraoperatively | Details |
| 431 | 2022 Measure # 431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | no | 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 12 months AND who received brief counseling if identified as an unhealthy alcohol user | Details |
| 432 | 2022 Measure # 432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | yes | Outcome | Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery | Details |
| 433 | 2022 Measure # 433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | yes | Outcome | Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery | Details |
| 436 | 2022 Measure # 436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | no | 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 | Details |
| 438 | 2022 Measure # 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | no | Process | Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:
•All patients who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
•Patients aged ≥ 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
•Patients aged 40-75 years with a diagnosis of diabetes | Details |
| 439 | 2022 Measure # 439 Age Appropriate Screening Colonoscopy | yes | Efficiency | The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31 | Details |
| 440 | 2022 Measure # 440 Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician | yes | Process | Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (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 |
| 441 | 2022 Measure # 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | yes | Intermediate Outcome | The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization’s total IVD denominator. | Details |
| 443 | 2022 Measure # 443 Non-Recommended Cervical Cancer Screening in Adolescent Females | yes | Process | The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer | Details |
| 445 | 2022 Measure # 445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | yes | Outcome | Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure. | Details |
| 448 | 2022 Measure # 448 Appropriate Workup Prior to Endometrial Ablation | yes | Process | Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation. | Details |
| 450 | 2022 Measure # 450 Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer | yes | Process | Percentage of female patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated | Details |
| 451 | 2022 Measure # 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 | no | Process | Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed | Details |
| 452 | 2022 Measure # 452 Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | yes | Process | Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies | Details |
| 453 | 2022 Measure # 453 Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better) | yes | Process | Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life. | Details |
| 455 | 2022 Measure # 455 Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better) | yes | Outcome | Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life. | Details |
| 457 | 2022 Measure # 457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) | yes | Outcome | Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there | 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 |
| 463 | 2022 Measure # 463 Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) | yes | 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 | 2022 Measure # 464 Otitis Media with Effusion: Systemic Antimicrobials | yes | Process | Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials | Details |
| 465 | 2022 Measure # 465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | yes | Process | The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries | Details |
| 468 | 2022 Measure # 468 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | yes | Process | Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment | 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 |
| 477 | 2022 Measure # 477 Multimodal Pain Management | yes | Process | Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine | 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 |
