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  • 2025 quality measures
  • 2024 quality measures

2025 quality measures

Quality IDMeasure NameCQMS PDFCollection Typehf:tax:collection_types
1Diabetes: Glycemic Status Assessment Greater Than 9%

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5Heart 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)

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6Coronary Artery Disease (CAD): Antiplatelet Therapy

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7Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)

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8Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

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24Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

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39Screening for Osteoporosis for Women Aged 65-85 Years of Age

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47Advance Care Plan

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48Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

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50Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

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52Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy

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65Appropriate Treatment for Upper Respiratory Infection (URI)

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66Appropriate Testing for Pharyngitis

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102Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

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112Breast Cancer Screening

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113Colorectal Cancer Screening

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116Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis

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117Diabetes: Eye Exam

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118Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)

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126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy — Neurological Evaluation

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127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear‌‌‌‌‌‌‌

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128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

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130Documentation of Current Medications in the Medical Record

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134Preventive Care and Screening: Screening for Depression and Follow-Up Plan

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141Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care

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143Oncology: Medical and Radiation – Pain Intensity Quantified

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144Oncology: Medical and Radiation – Plan of Care for Pain

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145Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy

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155Falls: Plan of Care

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164Coronary Artery Bypass Graft (CABG): Prolonged Intubation

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167Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

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168Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

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176Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy

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177Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

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178Rheumatoid Arthritis (RA): Functional Status Assessment

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180Rheumatoid Arthritis (RA): Glucocorticoid Management

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181Elder Maltreatment Screen and Follow-Up Plan

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182Functional Outcome Assessment

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185Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

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187Stroke and Stroke Rehabilitation: Thrombolytic Therapy‌‌‌‌‌‌

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191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

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205Sexually Transmitted Infection (STI) Testing for People with HIV

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217Functional Status Change for Patients with Knee Impairments

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218Functional Status Change for Patients with Hip Impairments

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219Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments

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220Functional Status Change for Patients with Low Back Impairments

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221Functional Status Change for Patients with Shoulder Impairments

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222Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

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226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

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236Controlling High Blood Pressure

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238Use of High-Risk Medications in Older Adults

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243Cardiac Rehabilitation Patient Referral from an Outpatient Setting

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249Barrett’s Esophagus

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250Radical Prostatectomy Pathology Reporting

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259Rate 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)

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261Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

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264Sentinel Lymph Node Biopsy for Invasive Breast Cancer

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268Counseling for Women of Childbearing Potential with Epilepsy

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275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

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277Sleep Apnea: Severity Assessment at Initial Diagnosis

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279Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy

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282Dementia: Functional Status Assessment

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286Safety Concern Screening and Follow-Up for Patients with Dementia

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288Dementia: Education and Support of Caregivers for Patients with Dementia

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290Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease

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291Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease

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293Rehabilitative Therapy Referral for Patients with Parkinson’s Disease

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303Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

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304Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

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317Preventive Care and Screening: Screening for High Blood Pressure and Follow- Up Documented

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320Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

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322Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients

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326Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

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331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

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332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

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335Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)

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336Maternity Care: Postpartum Follow-up and Care Coordination

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338HIV Viral Suppression

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340HIV Annual Retention in Care

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344Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

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350Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

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351Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

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354Anastomotic Leak Intervention

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355Unplanned Reoperation within the 30-Day Postoperative Period

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357Surgical Site Infection (SSI)

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358Patient-Centered Surgical Risk Assessment and Communication

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360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

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364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

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370Depression Remission at Twelve Months

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374Closing the Referral Loop: Receipt of Specialist Report

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384Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

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385Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

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386Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

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387Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

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389Cataract Surgery: Difference Between Planned and Final Refraction

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392Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

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393Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

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394Immunizations for Adolescents

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395Lung Cancer Reporting (Biopsy/Cytology Specimens)

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396Lung Cancer Reporting (Resection Specimens)

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397Melanoma Reporting

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398Optimal Asthma Control

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400One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation

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401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

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404Anesthesiology Smoking Abstinence

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405Appropriate Follow-up Imaging for Incidental Abdominal Lesions

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406Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

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410Psoriasis: Clinical Response to Systemic Medications

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413Door to Puncture Time for Endovascular Stroke Treatment

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415Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

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416Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years

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418Osteoporosis Management in Women Who Had a Fracture

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419Overuse of Imaging for the Evaluation of Primary Headache

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420Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

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421Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal

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422Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

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424Perioperative Temperature Management

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430Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

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431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

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432Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair

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438Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

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440Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician

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441Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

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443Non-Recommended Cervical Cancer Screening in Adolescent Females

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445Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

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448Appropriate Workup Prior to Endometrial Ablation

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450Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer

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451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy

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453Percentage of Patients who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)

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457Percentage of Patients who Died from Cancer Admitted to Hospice for Less than 3 Days (lower score – better)

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459Back Pain After Lumbar Surgery

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461Leg Pain After Lumbar Surgery

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463Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer

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464Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use

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465Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

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468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

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470Functional Status After Primary Total Knee Replacement

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471Functional Status After Lumbar Surgery

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477Multimodal Pain Management

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478Functional Status Change for Patients with Neck Impairments

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482Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate

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483Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)

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485Improvement in Patient-Reported Itch Severity

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486Dermatitis – Improvement in Patient-Reported Itch Severity

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487Screening for Social Drivers of Health

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488Kidney Health Evaluation

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489Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy

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490Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors

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491Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status

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493Adult Immunization Status

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495Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood

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496Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument‌

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497Preventive Care and Wellness (Composite)

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498Connection to Community Service Provider

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499Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy

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500Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up

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501Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up

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502Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder

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503Gains in Patient Activation Measure (PAM) Scores at 12 Months

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504Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide Risk

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505Reduction in Suicidal Ideation or Behavior Symptoms

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506Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy‌‌‌

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507Appropriate Germline Testing for Ovarian Cancer Patients

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508Adult COVID-19 Vaccination Status

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509Melanoma: Tracking and Evaluation of Recurrence

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510First Year Standardized Waitlist Ratio (FYSWR)

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511Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)

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356Unplanned Hospital Readmission within 30 Days of Principal Procedure

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476Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

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379Primary Caries Prevention Intervention as Offered by Dentists

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305Initiation and Engagement of Substance Use Disorder Treatment

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481Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer

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475HIV Screening

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376Functional Status Assessment for Total Hip Replacement

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377 Functional Status Assessments for Heart Failure

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366 Follow-Up Care for Children Prescribed ADHD Medication (ADD)

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318Falls: Screening for Future Fall Risk

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1056 Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)

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19Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

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281Dementia: Cognitive Assessment

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310Chlamydia Screening in Women

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378Children Who Have Dental Decay or Cavities

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309Cervical Cancer Screening

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462Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

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382Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

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240Childhood Immunization Status

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12Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

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239Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

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9Anti-depressant Medication Management

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2024 quality measures

Quality IDMeasure NamePDFCollection Typeshf:tax:collection_types
1Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%), Detailsecqm 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), Detailsecqm mips-cqm-2
6 Coronary Artery Disease (CAD): Antiplatelet TherapyDetailsmips-cqm-2
7 Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%), Detailsecqm mips-cqm-2
8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD), Detailsecqm mips-cqm-2
19 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care, Detailsecqm 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 OlderDetailsmips-cqm-2
39 Screening for Osteoporosis for Women Aged 65-85 Years of AgeDetailsmips-cqm-2
47Advance Care PlanDetailsmips-cqm-2
48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OlderDetailsmips-cqm-2
50 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderDetailsmips-cqm-2
52 Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator TherapyDetailsmips-cqm-2
65 Appropriate Treatment for Upper Respiratory Infection (URI), Detailsecqm mips-cqm-2
66 Appropriate Testing for Pharyngitis, Detailsecqm mips-cqm-2
102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients, Detailsecqm mips-cqm-2
104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate CancerDetailsmips-cqm-2
112 Breast Cancer Screening, Detailsecqm mips-cqm-2
113 Colorectal Cancer ScreeningDetailsmips-cqm-2
116 Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisDetailsmips-cqm-2
117 Diabetes: Eye Exam, Detailsecqm 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%)Detailsmips-cqm-2
126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationDetailsmips-cqm-2
127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of FootwearDetailsmips-cqm-2
128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan, Detailsecqm mips-cqm-2
130Documentation of Current Medications in the Medical Record, Detailsecqm mips-cqm-2
134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan, Detailsecqm mips-cqm-2
137 Melanoma: Continuity of Care – Recall SystemDetailsmips-cqm-2
141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of CareDetailsmips-cqm-2
143 Oncology: Medical and Radiation – Pain Intensity Quantified, Detailsecqm mips-cqm-2
144 Oncology: Medical and Radiation – Plan of Care for PainDetailsmips-cqm-2
145 Radiology: Exposure Dose Indices Reported for Procedures Using FluoroscopyDetailsmips-cqm-2
155 Falls: Plan of CareDetailsmips-cqm-2
164 Coronary Artery Bypass Graft (CABG): Prolonged IntubationDetailsmips-cqm-2
167 Coronary Artery Bypass Graft (CABG): Postoperative Renal FailureDetailsmips-cqm-2
168 Coronary Artery Bypass Graft (CABG): Surgical Re-ExplorationDetailsmips-cqm-2
176 Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier TherapyDetailsmips-cqm-2
177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease ActivityDetailsmips-cqm-2
178 Rheumatoid Arthritis (RA): Functional Status AssessmentDetailsmips-cqm-2
180 Rheumatoid Arthritis (RA): Glucocorticoid ManagementDetailsmips-cqm-2
181 Elder Maltreatment Screen and Follow-Up PlanDetailsmips-cqm-2
182 Functional Outcome AssessmentDetailsmips-cqm-2
185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate UseDetailsmips-cqm-2
187 Stroke and Stroke Rehabilitation: Thrombolytic TherapyDetailsmips-cqm-2
191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery, Detailsecqm mips-cqm-2
205Sexually Transmitted Infection (STI) Testing for People with HIV, Detailsecqm mips-cqm-2
217 Functional Status Change for Patients with Knee ImpairmentsDetailsmips-cqm-2
218 Functional Status Change for Patients with Hip ImpairmentsDetailsmips-cqm-2
219 Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsDetailsmips-cqm-2
220 Functional Status Change for Patients with Low Back ImpairmentsDetailsmips-cqm-2
221 Functional Status Change for Patients with Shoulder ImpairmentsDetailsmips-cqm-2
222 Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsDetailsmips-cqm-2
226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention, Detailsecqm mips-cqm-2
236Controlling High Blood Pressure, Detailsecqm mips-cqm-2
238 Use of High-Risk Medications in Older Adults, Detailsecqm mips-cqm-2
243 Cardiac Rehabilitation Patient Referral from an Outpatient SettingDetailsmips-cqm-2
249 Barrett’s EsophagusDetailsmips-cqm-2
250 Radical Prostatectomy Pathology ReportingDetailsmips-cqm-2
254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain or Vaginal BleedingDetailsmips-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)Detailsmips-cqm-2
260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)Detailsmips-cqm-2
261 Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessDetailsmips-cqm-2
264 Sentinel Lymph Node Biopsy for Invasive Breast CancerDetailsmips-cqm-2
268 Epilepsy: Counseling for Women of Childbearing Potential with EpilepsyDetailsmips-cqm-2
275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyDetailsmips-cqm-2
277 Sleep Apnea: Severity Assessment at Initial DiagnosisDetailsmips-cqm-2
279 Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) TherapyDetailsmips-cqm-2
282 Dementia: Functional Status AssessmentDetailsmips-cqm-2
286 Dementia: Safety Concern Screening and Follow-Up for Patients with DementiaDetailsmips-cqm-2
288 Dementia: Education and Support of Caregivers for Patients with DementiaDetailsmips-cqm-2
290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s DiseaseDetailsmips-cqm-2
291 Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s DiseaseDetailsmips-cqm-2
293 Rehabilitative Therapy Referral for Patients with Parkinson’s DiseaseDetailsmips-cqm-2
303 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryDetailsmips-cqm-2
304 Cataracts: Patient Satisfaction within 90 Days Following Cataract SurgeryDetailsmips-cqm-2
317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented, Detailsecqm mips-cqm-2
320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsDetailsmips-cqm-2
322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery PatientsDetailsmips-cqm-2
326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapyDetailsmips-cqm-2
331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)Detailsmips-cqm-2
332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)Detailsmips-cqm-2
335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)Detailsmips-cqm-2
336 Maternity Care: Postpartum Follow-Up and Care CoordinationDetailsmips-cqm-2
338 HIV Viral Suppression, Detailsecqm mips-cqm-2
340 HIV Medical Visit FrequencyDetailsmips-cqm-2
344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)Detailsmips-cqm-2
350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) TherapyDetailsmips-cqm-2
351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationDetailsmips-cqm-2
354 Anastomotic Leak InterventionDetailsmips-cqm-2
355 Unplanned Reoperation within the 30 Day Postoperative PeriodDetailsmips-cqm-2
356 Unplanned Hospital Readmission within 30 Days of Principal ProcedureDetailsmips-cqm-2
357 Surgical Site Infection (SSI)Detailsmips-cqm-2
358 Patient-Centered Surgical Risk Assessment and CommunicationDetailsmips-cqm-2
360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesDetailsmips-cqm-2
364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesDetailsmips-cqm-2
370 Depression Remission at Twelve Months, Detailsecqm mips-cqm-2
374Closing the Referral Loop: Receipt of Specialist Report, Detailsecqm mips-cqm-2
383 Adherence to Antipsychotic Medications for Individuals with SchizophreniaDetailsmips-cqm-2
384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of SurgeryDetailsmips-cqm-2
385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of SurgeryDetailsmips-cqm-2
386 Amyotrophic Lateral Sclerosis (ALS) Patient Care PreferencesDetailsmips-cqm-2
387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug UsersDetailsmips-cqm-2
389 Cataract Surgery: Difference Between Planned and Final RefractionDetailsmips-cqm-2
392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation AblationDetailsmips-cqm-2
393 Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or RevisionDetailsmips-cqm-2
394 Immunizations for AdolescentsDetailsmips-cqm-2
395 Lung Cancer Reporting (Biopsy/Cytology Specimens)Detailsmips-cqm-2
396 Lung Cancer Reporting (Resection Specimens)Detailsmips-cqm-2
397 Melanoma ReportingDetailsmips-cqm-2
398 Optimal Asthma ControlDetailsmips-cqm-2
400 One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation Detailsmips-cqm-2
401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisDetailsmips-cqm-2
404 Anesthesiology Smoking AbstinenceDetailsmips-cqm-2
405 Appropriate Follow-up Imaging for Incidental Abdominal LesionsDetailsmips-cqm-2
406 Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in PatientsDetailsmips-cqm-2
409 Clinical Outcome Post-Endovascular Stroke TreatmentDetailsmips-cqm-2
410 Psoriasis: Clinical Response to Systemic MedicationsDetailsmips-cqm-2
413 Door to Puncture Time for Endovascular Stroke TreatmentDetailsmips-cqm-2
415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderDetailsmips-cqm-2
416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 YearsDetailsmips-cqm-2
418 Osteoporosis Management in Women Who Had a FractureDetailsmips-cqm-2
419 Overuse of Imaging for the Evaluation of Primary HeadacheDetailsmips-cqm-2
420 Varicose Vein Treatment with Saphenous Ablation: Outcome SurveyDetailsmips-cqm-2
421 Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for RemovalDetailsmips-cqm-2
422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract InjuryDetailsmips-cqm-2
424 Perioperative Temperature ManagementDetailsmips-cqm-2
430 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination TherapyDetailsmips-cqm-2
431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingDetailsmips-cqm-2
432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse RepairDetailsmips-cqm-2
433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse RepairDetailsmips-cqm-2
436 Radiation Consideration for Adult CT: Utilization of Dose Lowering TechniquesDetailsmips-cqm-2
438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, Detailsecqm mips-cqm-2
439 Age Appropriate Screening ColonoscopyDetailsmips-cqm-2
440 Skin Cancer: Biopsy Reporting Time – Pathologist to ClinicianDetailsmips-cqm-2
441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)Detailsmips-cqm-2
443 Non-Recommended Cervical Cancer Screening in Adolescent FemalesDetailsmips-cqm-2
445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)Detailsmips-cqm-2
448 Appropriate Workup Prior to Endometrial AblationDetailsmips-cqm-2
450Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast CancerDetailsmips-cqm-2
451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody TherapyDetailsmips-cqm-2
452Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal AntibodiesDetailsmips-cqm-2
453Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)Detailsmips-cqm-2
457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)Detailsmips-cqm-2
459 Back Pain After Lumbar SurgeryDetailsmips-cqm-2
461 Leg Pain After Lumbar SurgeryDetailsmips-cqm-2
463 Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)Detailsmips-cqm-2
464 Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate UseDetailsmips-cqm-2
465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian ArteriesDetailsmips-cqm-2
468 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)Detailsmips-cqm-2
470 Functional Status After Primary Total Knee ReplacementDetailsmips-cqm-2
471 Functional Status After Lumbar SurgeryDetailsmips-cqm-2
477 Multimodal Pain ManagementDetailsmips-cqm-2
478 Functional Status Change for Patients with Neck ImpairmentsDetailsmips-cqm-2
482 Hemodialysis Vascular Access: Practitioner Level Long-term Catheter RateDetailsmips-cqm-2
483 Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)Detailsmips-cqm-2
485 Psoriasis – Improvement in Patient-Reported Itch SeverityDetailsmips-cqm-2
486 Dermatitis – Improvement in Patient-Reported Itch SeverityDetailsmips-cqm-2
487 Screening for Social Drivers of HealthDetailsmips-cqm-2
488 Kidney Health Evaluation, Detailsecqm mips-cqm-2
489 Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) TherapyDetailsmips-cqm-2
490 Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint InhibitorsDetailsmips-cqm-2
491 Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaDetailsmips-cqm-2
493 Adult Immunization StatusDetailsmips-cqm-2
495Ambulatory Palliative Care Patients’ Experience of Feeling Heard and UnderstoodDetailsmips-cqm-2
496Cardiovascular Disease (CVD) Risk Assessment Measure – Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized InstrumentDetailsmips-cqm-2
497Preventive Care and Wellness (Composite)Detailsmips-cqm-2
498Connection to Community Service ProviderDetailsmips-cqm-2
499Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid TherapyDetailsmips-cqm-2
500Acute Posterior Vitreous Detachment Appropriate Examination and Follow-upDetailsmips-cqm-2
501Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-upDetailsmips-cqm-2
502Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use DisorderDetailsmips-cqm-2
503Quality ID #503 (CBE 2483): Gains in Patient Activation Measure (PAM) Scores at 12 MonthsDetailsmips-cqm-2
504Initiation, Review, and/or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, or Suicide RiskDetailsmips-cqm-2
505Quality ID #505: Reduction in Suicidal Ideation or Behavior SymptomsDetailsmips-cqm-2