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