Quality measures

2025 quality measures
2024 quality measures

2025 quality measures

Quality ID	Measure Name	Collection Type	hf:tax:collection_types
1	Diabetes: Glycemic Status Assessment Greater Than 9%	CQM eCQM	cqms
5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CQM eCQM	cqms
6	Coronary Artery Disease (CAD): Antiplatelet Therapy	CQM	cqms
7	Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	CQM eCQM	cqms
8	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CQM eCQM	cqms
24	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	CQM	cqms
39	Screening for Osteoporosis for Women Aged 65-85 Years of Age	CQM	cqms
47	Advance Care Plan	CQM	cqms
48	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	CQM	cqms
50	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	CQM	cqms
52	Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy	CQM	cqms
65	Appropriate Treatment for Upper Respiratory Infection (URI)	CQM eCQM	cqms
66	Appropriate Testing for Pharyngitis	CQM eCQM	cqms
102	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	CQM eCQM	cqms
112	Breast Cancer Screening	CQM eCQM	cqms
113	Colorectal Cancer Screening	CQM eCQM	cqms
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	CQM	cqms
117	Diabetes: Eye Exam	CQM eCQM	cqms
118	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	CQM	cqms
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy — Neurological Evaluation	CQM	cqms
127	Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear‌‌‌‌‌‌‌	CQM	cqms
128	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	CQM eCQM	cqms
130	Documentation of Current Medications in the Medical Record	CQM eCQM	cqms
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	CQM eCQM	cqms
141	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care	CQM	cqms
143	Oncology: Medical and Radiation – Pain Intensity Quantified	CQM eCQM	cqms
144	Oncology: Medical and Radiation – Plan of Care for Pain	CQM	cqms
145	Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy	CQM	cqms
155	Falls: Plan of Care	CQM	cqms
164	Coronary Artery Bypass Graft (CABG): Prolonged Intubation	CQM	cqms
167	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure	CQM	cqms
168	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration	CQM	cqms
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	CQM	cqms
177	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity	CQM	cqms
178	Rheumatoid Arthritis (RA): Functional Status Assessment	CQM	cqms
180	Rheumatoid Arthritis (RA): Glucocorticoid Management	CQM	cqms
181	Elder Maltreatment Screen and Follow-Up Plan	CQM	cqms
182	Functional Outcome Assessment	CQM	cqms
185	Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use	CQM	cqms
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy‌‌‌‌‌‌	CQM	cqms
191	Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	CQM eCQM	cqms
205	Sexually Transmitted Infection (STI) Testing for People with HIV	CQM eCQM	cqms
217	Functional Status Change for Patients with Knee Impairments	CQM	cqms
218	Functional Status Change for Patients with Hip Impairments	CQM	cqms
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	CQM	cqms
220	Functional Status Change for Patients with Low Back Impairments	CQM	cqms
221	Functional Status Change for Patients with Shoulder Impairments	CQM	cqms
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	CQM	cqms
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CQM eCQM	cqms
236	Controlling High Blood Pressure	CQM eCQM	cqms
238	Use of High-Risk Medications in Older Adults	CQM eCQM	cqms
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	CQM	cqms
249	Barrett’s Esophagus	CQM	cqms
250	Radical Prostatectomy Pathology Reporting	CQM	cqms
259	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)	CQM	cqms
261	Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness	CQM	cqms
264	Sentinel Lymph Node Biopsy for Invasive Breast Cancer	CQM	cqms
268	Counseling for Women of Childbearing Potential with Epilepsy	CQM	cqms
275	Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy	CQM	cqms
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	CQM	cqms
279	Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy	CQM	cqms
282	Dementia: Functional Status Assessment	CQM	cqms
286	Safety Concern Screening and Follow-Up for Patients with Dementia	CQM	cqms
288	Dementia: Education and Support of Caregivers for Patients with Dementia	CQM	cqms
290	Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease	CQM	cqms
291	Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease	CQM	cqms
293	Rehabilitative Therapy Referral for Patients with Parkinson’s Disease	CQM	cqms
303	Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery	CQM	cqms
304	Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery	CQM	cqms
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow- Up Documented	CQM eCQM	cqms
320	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	CQM	cqms
322	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients	CQM	cqms
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	CQM	cqms
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	CQM	cqms
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	CQM	cqms
335	Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)	CQM	cqms
336	Maternity Care: Postpartum Follow-up and Care Coordination	CQM	cqms
338	HIV Viral Suppression	CQM eCQM	cqms
340	HIV Annual Retention in Care	CQM eCQM	cqms
344	Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	CQM	cqms
350	Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy	CQM	cqms
351	Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation	CQM	cqms
354	Anastomotic Leak Intervention	CQM	cqms
355	Unplanned Reoperation within the 30-Day Postoperative Period	CQM	cqms
357	Surgical Site Infection (SSI)	CQM	cqms
358	Patient-Centered Surgical Risk Assessment and Communication	CQM	cqms
360	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies	CQM	cqms
364	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines	CQM	cqms
370	Depression Remission at Twelve Months	CQM eCQM	cqms
374	Closing the Referral Loop: Receipt of Specialist Report	CQM eCQM	cqms
384	Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery	CQM	cqms
385	Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery	CQM	cqms
386	Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences	CQM	cqms
387	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users	CQM	cqms
389	Cataract Surgery: Difference Between Planned and Final Refraction	CQM	cqms
392	Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation	CQM	cqms
393	Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision	CQM	cqms
394	Immunizations for Adolescents	CQM	cqms
395	Lung Cancer Reporting (Biopsy/Cytology Specimens)	CQM	cqms
396	Lung Cancer Reporting (Resection Specimens)	CQM	cqms
397	Melanoma Reporting	CQM	cqms
398	Optimal Asthma Control	CQM	cqms
400	One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation	CQM	cqms
401	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis	CQM	cqms
404	Anesthesiology Smoking Abstinence	CQM	cqms
405	Appropriate Follow-up Imaging for Incidental Abdominal Lesions	CQM	cqms
406	Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients	CQM	cqms
410	Psoriasis: Clinical Response to Systemic Medications	CQM	cqms
413	Door to Puncture Time for Endovascular Stroke Treatment	CQM	cqms
415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	CQM	cqms
416	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years	CQM	cqms
418	Osteoporosis Management in Women Who Had a Fracture	CQM	cqms
419	Overuse of Imaging for the Evaluation of Primary Headache	CQM	cqms
420	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey	CQM	cqms
421	Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal	CQM	cqms
422	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury	CQM	cqms
424	Perioperative Temperature Management	CQM	cqms
430	Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy	CQM	cqms
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	CQM	cqms
432	Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair	CQM	cqms
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CQM eCQM	cqms
440	Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician	CQM	cqms
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	CQM	cqms
443	Non-Recommended Cervical Cancer Screening in Adolescent Females	CQM	cqms
445	Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)	CQM	cqms
448	Appropriate Workup Prior to Endometrial Ablation	CQM	cqms
450	Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer	CQM	cqms
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	CQM	cqms
453	Percentage of Patients who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)	CQM	cqms
457	Percentage of Patients who Died from Cancer Admitted to Hospice for Less than 3 Days (lower score – better)	CQM	cqms
459	Back Pain After Lumbar Surgery	CQM	cqms
461	Leg Pain After Lumbar Surgery	CQM	cqms
463	Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer	CQM	cqms
464	Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use	CQM	cqms
465	Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries	CQM	cqms
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	CQM	cqms
470	Functional Status After Primary Total Knee Replacement	CQM	cqms
471	Functional Status After Lumbar Surgery	CQM	cqms
477	Multimodal Pain Management	CQM	cqms
478	Functional Status Change for Patients with Neck Impairments	CQM	cqms
482	Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate	CQM	cqms
483	Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)	CQM	cqms
485	Improvement in Patient-Reported Itch Severity	CQM	cqms
486	Dermatitis – Improvement in Patient-Reported Itch Severity	CQM	cqms
487	Screening for Social Drivers of Health	CQM	cqms
488	Kidney Health Evaluation	CQM eCQM	cqms
489	Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	CQM	cqms
490	Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors	CQM	cqms
491	Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status	CQM	cqms
493	Adult Immunization Status	CQM	cqms
495	Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood	CQM	cqms
496	Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument‌	CQM	cqms
497	Preventive Care and Wellness (Composite)	CQM	cqms
498	Connection to Community Service Provider	CQM	cqms
499	Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy	CQM	cqms
500	Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up	CQM	cqms
501	Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up	CQM	cqms
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	CQM	cqms
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	CQM	cqms
504	Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk	CQM	cqms
505	Reduction in Suicidal Ideation or Behavior Symptoms	CQM	cqms
506	Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy‌‌‌	CQM	cqms
507	Appropriate Germline Testing for Ovarian Cancer Patients	CQM	cqms
508	Adult COVID-19 Vaccination Status	CQM	cqms
509	Melanoma: Tracking and Evaluation of Recurrence	CQM	cqms
510	First Year Standardized Waitlist Ratio (FYSWR)	CQM	cqms
511	Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)	CQM	cqms
356	Unplanned Hospital Readmission within 30 Days of Principal Procedure	CQM	cqms
476	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	eCQM	cqms
379	Primary Caries Prevention Intervention as Offered by Dentists	eCQM	cqms
305	Initiation and Engagement of Substance Use Disorder Treatment	eCQM	cqms
481	Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer	eCQM	cqms
475	HIV Screening	eCQM	cqms
376	Functional Status Assessment for Total Hip Replacement	eCQM	cqms
377	Functional Status Assessments for Heart Failure	eCQM	cqms
366	Follow-Up Care for Children Prescribed ADHD Medication (ADD)	eCQM	cqms
318	Falls: Screening for Future Fall Risk	eCQM	cqms
1056	Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)	eCQM	cqms
19	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	eCQM	cqms
281	Dementia: Cognitive Assessment	eCQM	cqms
310	Chlamydia Screening in Women	eCQM	cqms
378	Children Who Have Dental Decay or Cavities	eCQM	cqms
309	Cervical Cancer Screening	eCQM	cqms
462	Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy	eCQM	cqms
382	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	eCQM	cqms
240	Childhood Immunization Status	eCQM	cqms
12	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	eCQM	cqms
239	Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents	eCQM	cqms
9	Anti-depressant Medication Management	eCQM	cqms

2024 quality measures

Quality ID	Measure Name	Collection Types		hf:tax:collection_types
1	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
5	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
6	Coronary Artery Disease (CAD): Antiplatelet Therapy	MIPS/CQM	Details	mips-cqm-2
7	Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%)	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
8	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
19	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
24	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	MIPS/CQM	Details	mips-cqm-2
39	Screening for Osteoporosis for Women Aged 65-85 Years of Age	MIPS/CQM	Details	mips-cqm-2
47	Advance Care Plan	MIPS/CQM	Details	mips-cqm-2
48	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	MIPS/CQM	Details	mips-cqm-2
50	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	MIPS/CQM	Details	mips-cqm-2
52	Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy	MIPS/CQM	Details	mips-cqm-2
65	Appropriate Treatment for Upper Respiratory Infection (URI)	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
66	Appropriate Testing for Pharyngitis	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
102	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
104	Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer	MIPS/CQM	Details	mips-cqm-2
112	Breast Cancer Screening	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
113	Colorectal Cancer Screening	MIPS/CQM	Details	mips-cqm-2
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	MIPS/CQM	Details	mips-cqm-2
117	Diabetes: Eye Exam	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
118	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF <= 40%)	MIPS/CQM	Details	mips-cqm-2
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation	MIPS/CQM	Details	mips-cqm-2
127	Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear	MIPS/CQM	Details	mips-cqm-2
128	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
130	Documentation of Current Medications in the Medical Record	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
137	Melanoma: Continuity of Care – Recall System	MIPS/CQM	Details	mips-cqm-2
141	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care	MIPS/CQM	Details	mips-cqm-2
143	Oncology: Medical and Radiation – Pain Intensity Quantified	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
144	Oncology: Medical and Radiation – Plan of Care for Pain	MIPS/CQM	Details	mips-cqm-2
145	Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy	MIPS/CQM	Details	mips-cqm-2
155	Falls: Plan of Care	MIPS/CQM	Details	mips-cqm-2
164	Coronary Artery Bypass Graft (CABG): Prolonged Intubation	MIPS/CQM	Details	mips-cqm-2
167	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure	MIPS/CQM	Details	mips-cqm-2
168	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration	MIPS/CQM	Details	mips-cqm-2
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	MIPS/CQM	Details	mips-cqm-2
177	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity	MIPS/CQM	Details	mips-cqm-2
178	Rheumatoid Arthritis (RA): Functional Status Assessment	MIPS/CQM	Details	mips-cqm-2
180	Rheumatoid Arthritis (RA): Glucocorticoid Management	MIPS/CQM	Details	mips-cqm-2
181	Elder Maltreatment Screen and Follow-Up Plan	MIPS/CQM	Details	mips-cqm-2
182	Functional Outcome Assessment	MIPS/CQM	Details	mips-cqm-2
185	Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use	MIPS/CQM	Details	mips-cqm-2
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	MIPS/CQM	Details	mips-cqm-2
191	Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
205	Sexually Transmitted Infection (STI) Testing for People with HIV	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
217	Functional Status Change for Patients with Knee Impairments	MIPS/CQM	Details	mips-cqm-2
218	Functional Status Change for Patients with Hip Impairments	MIPS/CQM	Details	mips-cqm-2
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	MIPS/CQM	Details	mips-cqm-2
220	Functional Status Change for Patients with Low Back Impairments	MIPS/CQM	Details	mips-cqm-2
221	Functional Status Change for Patients with Shoulder Impairments	MIPS/CQM	Details	mips-cqm-2
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	MIPS/CQM	Details	mips-cqm-2
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
236	Controlling High Blood Pressure	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
238	Use of High-Risk Medications in Older Adults	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	MIPS/CQM	Details	mips-cqm-2
249	Barrett’s Esophagus	MIPS/CQM	Details	mips-cqm-2
250	Radical Prostatectomy Pathology Reporting	MIPS/CQM	Details	mips-cqm-2
254	Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain or Vaginal Bleeding	MIPS/CQM	Details	mips-cqm-2
259	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)	MIPS/CQM	Details	mips-cqm-2
260	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)	MIPS/CQM	Details	mips-cqm-2
261	Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness	MIPS/CQM	Details	mips-cqm-2
264	Sentinel Lymph Node Biopsy for Invasive Breast Cancer	MIPS/CQM	Details	mips-cqm-2
268	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy	MIPS/CQM	Details	mips-cqm-2
275	Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy	MIPS/CQM	Details	mips-cqm-2
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	MIPS/CQM	Details	mips-cqm-2
279	Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy	MIPS/CQM	Details	mips-cqm-2
282	Dementia: Functional Status Assessment	MIPS/CQM	Details	mips-cqm-2
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	MIPS/CQM	Details	mips-cqm-2
288	Dementia: Education and Support of Caregivers for Patients with Dementia	MIPS/CQM	Details	mips-cqm-2
290	Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease	MIPS/CQM	Details	mips-cqm-2
291	Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease	MIPS/CQM	Details	mips-cqm-2
293	Rehabilitative Therapy Referral for Patients with Parkinson’s Disease	MIPS/CQM	Details	mips-cqm-2
303	Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery	MIPS/CQM	Details	mips-cqm-2
304	Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery	MIPS/CQM	Details	mips-cqm-2
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
320	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	MIPS/CQM	Details	mips-cqm-2
322	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients	MIPS/CQM	Details	mips-cqm-2
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	MIPS/CQM	Details	mips-cqm-2
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	MIPS/CQM	Details	mips-cqm-2
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	MIPS/CQM	Details	mips-cqm-2
335	Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)	MIPS/CQM	Details	mips-cqm-2
336	Maternity Care: Postpartum Follow-Up and Care Coordination	MIPS/CQM	Details	mips-cqm-2
338	HIV Viral Suppression	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
340	HIV Medical Visit Frequency	MIPS/CQM	Details	mips-cqm-2
344	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	MIPS/CQM	Details	mips-cqm-2
350	Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy	MIPS/CQM	Details	mips-cqm-2
351	Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation	MIPS/CQM	Details	mips-cqm-2
354	Anastomotic Leak Intervention	MIPS/CQM	Details	mips-cqm-2
355	Unplanned Reoperation within the 30 Day Postoperative Period	MIPS/CQM	Details	mips-cqm-2
356	Unplanned Hospital Readmission within 30 Days of Principal Procedure	MIPS/CQM	Details	mips-cqm-2
357	Surgical Site Infection (SSI)	MIPS/CQM	Details	mips-cqm-2
358	Patient-Centered Surgical Risk Assessment and Communication	MIPS/CQM	Details	mips-cqm-2
360	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies	MIPS/CQM	Details	mips-cqm-2
364	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines	MIPS/CQM	Details	mips-cqm-2
370	Depression Remission at Twelve Months	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
374	Closing the Referral Loop: Receipt of Specialist Report	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
383	Adherence to Antipsychotic Medications for Individuals with Schizophrenia	MIPS/CQM	Details	mips-cqm-2
384	Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery	MIPS/CQM	Details	mips-cqm-2
385	Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery	MIPS/CQM	Details	mips-cqm-2
386	Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences	MIPS/CQM	Details	mips-cqm-2
387	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users	MIPS/CQM	Details	mips-cqm-2
389	Cataract Surgery: Difference Between Planned and Final Refraction	MIPS/CQM	Details	mips-cqm-2
392	Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation	MIPS/CQM	Details	mips-cqm-2
393	Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision	MIPS/CQM	Details	mips-cqm-2
394	Immunizations for Adolescents	MIPS/CQM	Details	mips-cqm-2
395	Lung Cancer Reporting (Biopsy/Cytology Specimens)	MIPS/CQM	Details	mips-cqm-2
396	Lung Cancer Reporting (Resection Specimens)	MIPS/CQM	Details	mips-cqm-2
397	Melanoma Reporting	MIPS/CQM	Details	mips-cqm-2
398	Optimal Asthma Control	MIPS/CQM	Details	mips-cqm-2
400	One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation	MIPS/CQM	Details	mips-cqm-2
401	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis	MIPS/CQM	Details	mips-cqm-2
404	Anesthesiology Smoking Abstinence	MIPS/CQM	Details	mips-cqm-2
405	Appropriate Follow-up Imaging for Incidental Abdominal Lesions	MIPS/CQM	Details	mips-cqm-2
406	Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients	MIPS/CQM	Details	mips-cqm-2
409	Clinical Outcome Post-Endovascular Stroke Treatment	MIPS/CQM	Details	mips-cqm-2
410	Psoriasis: Clinical Response to Systemic Medications	MIPS/CQM	Details	mips-cqm-2
413	Door to Puncture Time for Endovascular Stroke Treatment	MIPS/CQM	Details	mips-cqm-2
415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	MIPS/CQM	Details	mips-cqm-2
416	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years	MIPS/CQM	Details	mips-cqm-2
418	Osteoporosis Management in Women Who Had a Fracture	MIPS/CQM	Details	mips-cqm-2
419	Overuse of Imaging for the Evaluation of Primary Headache	MIPS/CQM	Details	mips-cqm-2
420	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey	MIPS/CQM	Details	mips-cqm-2
421	Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal	MIPS/CQM	Details	mips-cqm-2
422	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury	MIPS/CQM	Details	mips-cqm-2
424	Perioperative Temperature Management	MIPS/CQM	Details	mips-cqm-2
430	Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy	MIPS/CQM	Details	mips-cqm-2
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	MIPS/CQM	Details	mips-cqm-2
432	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair	MIPS/CQM	Details	mips-cqm-2
433	Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair	MIPS/CQM	Details	mips-cqm-2
436	Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques	MIPS/CQM	Details	mips-cqm-2
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
439	Age Appropriate Screening Colonoscopy	MIPS/CQM	Details	mips-cqm-2
440	Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician	MIPS/CQM	Details	mips-cqm-2
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	MIPS/CQM	Details	mips-cqm-2
443	Non-Recommended Cervical Cancer Screening in Adolescent Females	MIPS/CQM	Details	mips-cqm-2
445	Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)	MIPS/CQM	Details	mips-cqm-2
448	Appropriate Workup Prior to Endometrial Ablation	MIPS/CQM	Details	mips-cqm-2
450	Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer	MIPS/CQM	Details	mips-cqm-2
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	MIPS/CQM	Details	mips-cqm-2
452	Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies	MIPS/CQM	Details	mips-cqm-2
453	Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)	MIPS/CQM	Details	mips-cqm-2
457	Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)	MIPS/CQM	Details	mips-cqm-2
459	Back Pain After Lumbar Surgery	MIPS/CQM	Details	mips-cqm-2
461	Leg Pain After Lumbar Surgery	MIPS/CQM	Details	mips-cqm-2
463	Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)	MIPS/CQM	Details	mips-cqm-2
464	Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use	MIPS/CQM	Details	mips-cqm-2
465	Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries	MIPS/CQM	Details	mips-cqm-2
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	MIPS/CQM	Details	mips-cqm-2
470	Functional Status After Primary Total Knee Replacement	MIPS/CQM	Details	mips-cqm-2
471	Functional Status After Lumbar Surgery	MIPS/CQM	Details	mips-cqm-2
477	Multimodal Pain Management	MIPS/CQM	Details	mips-cqm-2
478	Functional Status Change for Patients with Neck Impairments	MIPS/CQM	Details	mips-cqm-2
482	Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate	MIPS/CQM	Details	mips-cqm-2
483	Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)	MIPS/CQM	Details	mips-cqm-2
485	Psoriasis – Improvement in Patient-Reported Itch Severity	MIPS/CQM	Details	mips-cqm-2
486	Dermatitis – Improvement in Patient-Reported Itch Severity	MIPS/CQM	Details	mips-cqm-2
487	Screening for Social Drivers of Health	MIPS/CQM	Details	mips-cqm-2
488	Kidney Health Evaluation	eCQM, MIPS/CQM	Details	ecqm mips-cqm-2
489	Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	MIPS/CQM	Details	mips-cqm-2
490	Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors	MIPS/CQM	Details	mips-cqm-2
491	Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma	MIPS/CQM	Details	mips-cqm-2
493	Adult Immunization Status	MIPS/CQM	Details	mips-cqm-2
495	Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood	MIPS/CQM	Details	mips-cqm-2
496	Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument	MIPS/CQM	Details	mips-cqm-2
497	Preventive Care and Wellness (Composite)	MIPS/CQM	Details	mips-cqm-2
498	Connection to Community Service Provider	MIPS/CQM	Details	mips-cqm-2
499	Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy	MIPS/CQM	Details	mips-cqm-2
500	Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up	MIPS/CQM	Details	mips-cqm-2
501	Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up	MIPS/CQM	Details	mips-cqm-2
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	MIPS/CQM	Details	mips-cqm-2
503	Quality ID #503 (CBE 2483): Gains in Patient Activation Measure (PAM) Scores at 12 Months	MIPS/CQM	Details	mips-cqm-2
504	Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk	MIPS/CQM	Details	mips-cqm-2
505	Quality ID #505: Reduction in Suicidal Ideation or Behavior Symptoms	MIPS/CQM	Details	mips-cqm-2