The 2023 MIPS reporting deadline is April 1, 2024. 

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2023 MIPS Quality Measures

  • 2023 Quality Measures
  • 2022 Quality Measures
Quality IdMeasure NamePDFMeasure TypeCollection Typehf:tax:collection_types
009Anti-depressant Medication ManagementProcesseCQMDetailsecqm
012Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationProcesseCQMDetailsecqm
107Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentProcesseCQMDetailsecqm
239Weight Assessment and Counseling for Nutrition and Physical Activity for Children and AdolescentsProcesseCQMDetailsecqm
240Childhood Immunization StatusProcesseCQMDetailsecqm
281Dementia: Cognitive AssessmentProcesseCQMDetailsecqm ecqm-mvp mvp
305Initiation and Engagement of Alcohol and Other Drug Dependence TreatmentProcesseCQMDetailsecqm
309Cervical Cancer ScreeningProcesseCQMDetailsecqm ecqm-mvp mvp
310Chlamydia Screening for WomenProcesseCQMDetailsecqm ecqm-mvp mvp
318Falls: Screening for Future Fall RiskProcesseCQMDetailsecqm
366Follow-Up Care for Children Prescribed ADHD Medication (ADD)ProcesseCQMDetailsecqm
375Functional Status Assessment for Total Knee ReplacementProcesseCQMDetailsecqm
376Functional Status Assessment for Total Hip ReplacementProcesseCQMDetailsecqm ecqm-mvp mvp
377Functional Status Assessments for Heart FailureProcesseCQMDetailsecqm ecqm-mvp mvp
378Children Who Have Dental Decay or CavitiesOutcomeeCQMDetailsecqm
379Primary Caries Prevention Intervention as Offered by Primary Care Providers, including DentistsProcesseCQMDetailsecqm
382Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentProcesseCQMDetailsecqm
462Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapyProcesseCQMDetailsecqm ecqm-mvp mvp
472Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureProcesseCQMDetailsecqm
475HIV ScreeningProcesseCQMDetailsecqm ecqm-mvp mvp
476Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiaPatient Reported Outcome PerformanceeCQMDetailsecqm
481Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancerProcesseCQMDetailsecqm
001Diabetes: Hemoglobin A1c Poor ControlProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
005Heart 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)ProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
006Coronary Artery Disease (CAD): Antiplatelet TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
007Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <= 40%)ProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
008Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)ProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
039Screening for Osteoporosis for Women Aged 65-85 Years of AgeProcessCQM, MVPDetailscqm cqm-mvp mvp
047Advance Care PlanProcessCQM, MVPDetailscqm cqm-mvp mvp
112Breast Cancer ScreeningProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
014Age-Related Macular Degeneration (AMD): Dilated Macular ExaminationProcessCQMDetailscqm
019Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OlderProcessCQMDetailscqm
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderProcessCQMDetailscqm
052Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator TherapyProcessCQMDetailscqm
065Appropriate Treatment for Upper Respiratory Infection (URI)ProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
066Appropriate Testing for PharyngitisProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
093Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseProcessCQMDetailscqm
102Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer PatientsProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
104Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate CancerProcessCQMDetailscqm
111Pneumococcal Vaccination Status for Older AdultsProcessCQM, eCQM, MVPDetailsmvp
113Colorectal Cancer ScreeningProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
116Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisProcessCQM, MVPDetailscqm cqm-mvp mvp
118Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF <= 40%)ProcessCQM, MVPDetailscqm cqm-mvp mvp
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
130Documentation of Current Medications in the Medical RecordProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
134Preventive Care and Screening: Screening for Depression and Follow-Up PlanProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
143Oncology: Medical and Radiation – Pain Intensity QuantifiedProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
144Oncology: Medical and Radiation – Plan of Care for PainProcessCQM, MVPDetailscqm cqm-mvp mvp
117Diabetes: Eye ExamProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationProcessCQMDetailscqm
127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of FootwearProcessCQMDetailscqm
137Melanoma: Continuity of Care – Recall SystemProcessCQMDetailscqm
138Melanoma: Coordination of CareProcessCQMDetailscqm
141Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of CareOutcomeCQMDetailscqm
145Radiology: Exposure Dose Indices Reported for Procedures Using FluoroscopyProcessCQMDetailscqm
147Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone ScintigraphyProcessCQMDetailscqm
155Falls: Plan of CareProcessCQMDetailscqm
164Coronary Artery Bypass Graft (CABG): Prolonged IntubationOutcomeCQMDetailscqm
167Coronary Artery Bypass Graft (CABG): Postoperative Renal FailureOutcomeCQMDetailscqm
168Coronary Artery Bypass Graft (CABG): Surgical Re-ExplorationOutcomeCQMDetailscqm
176Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
177Rheumatoid Arthritis (RA): Periodic Assessment of Disease ActivityProcessCQM, MVPDetailscqm cqm-mvp mvp
178Rheumatoid Arthritis (RA): Functional Status AssessmentProcessCQM, MVPDetailscqm cqm-mvp mvp
180Rheumatoid Arthritis (RA): Glucocorticoid ManagementProcessCQM, MVPDetailscqm cqm-mvp mvp
187Stroke and Stroke Rehabilitation: Thrombolytic TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
236Controlling High Blood PressureProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
238Use of High-Risk Medications in Older AdultsProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
243Cardiac Rehabilitation Patient Referral from an Outpatient SettingProcessCQM, MVPDetailscqm cqm-mvp mvp
181Elder Maltreatment Screen and Follow-Up PlanProcessCQMDetailscqm
182Functional Outcome AssessmentProcessCQMDetailscqm
185Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate UseProcessCQMDetailscqm
191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryOutcomeCQM, eCQMDetailscqm cqm-ecqm ecqm
205HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and SyphilisProcessCQMDetailscqm
217Functional Status Change for Patients with Knee ImpairmentsOutcomeCQMDetailscqm
218Functional Status Change for Patients with Hip ImpairmentsOutcomeCQMDetailscqm
219Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsOutcomeCQMDetailscqm
220Functional Status Change for Patients with Low Back ImpairmentsOutcomeCQMDetailscqm
221Functional Status Change for Patients with Shoulder ImpairmentsOutcomeCQMDetailscqm
249Barrett's EsophagusProcessCQMDetailscqm
254Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal PainProcessCQM, MVPDetailscqm cqm-mvp mvp
268Epilepsy: Counseling for Women of Childbearing Potential with EpilepsyProcessCQM, MVPDetailscqm cqm-mvp mvp
282Dementia: Functional Status AssessmentProcessCQM, MVPDetailscqm cqm-mvp mvp
286Dementia: Safety Concern Screening and Follow-Up for Patients with DementiaProcessCQM, MVPDetailscqm cqm-mvp mvp
288Dementia: Education and Support of Caregivers for Patients with DementiaProcessCQM, MVPDetailscqm cqm-mvp mvp
290Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s DiseaseProcessCQM, MVPDetailscqm cqm-mvp mvp
291Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's DiseaseProcessCQM, MVPDetailscqm cqm-mvp mvp
293Rehabilitative Therapy Referral for Patients with Parkinson's DiseaseProcessCQM, MVPDetailscqm cqm-mvp mvp
250Radical Prostatectomy Pathology ReportingProcessCQMDetailscqm
259Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)OutcomeCQMDetailscqm
260Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)OutcomeCQMDetailscqm
261Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessProcessCQMDetailscqm
264Sentinel Lymph Node Biopsy for Invasive Breast CancerProcessCQMDetailscqm
275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyProcessCQMDetailscqm
277Sleep Apnea: Severity Assessment at Initial DiagnosisProcessCQMDetailscqm
279Sleep Apnea: Assessment of Adherence to Positive Airway Pressure TherapyProcessCQMDetailscqm
283Dementia Associated Behavioral and Psychiatric Symptoms Screening and ManagementProcessCQMDetailscqm
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
320Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsProcessCQMDetailscqm
322Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery PatientsProcessCQMDetailscqm
326Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)ProcessCQM, MVPDetailscqm cqm-mvp mvp
344Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)OutcomeCQM, MVPDetailscqm cqm-mvp mvp
350Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Nonsurgical) TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
351Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationProcessCQM, MVPDetailscqm cqm-mvp mvp
324Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk PatientsProcessCQMDetailscqm
332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)ProcessCQMDetailscqm
335Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)OutcomeCQMDetailscqm
336Maternity Care: Postpartum Follow-Up and Care CoordinationProcessCQMDetailscqm
338HIV Viral Load SuppressionOutcomeCQMDetailscqm
340HIV Medical Visit FrequencyProcessCQMDetailscqm
354Anastomotic Leak InterventionOutcomeCQMDetailscqm
355Unplanned Reoperation within the 30 Day Postoperative PeriodOutcomeCQMDetailscqm
356Unplanned Hospital Readmission within 30 Days of Principal ProcedureOutcomeCQMDetailscqm
357Surgical Site Infection (SSI)OutcomeCQMDetailscqm
358Patient-Centered Surgical Risk Assessment and CommunicationProcessCQMDetailscqm
360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesProcessCQMDetailscqm
364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesProcessCQMDetailscqm
370Depression Remission at Twelve MonthsOutcomeCQM, eCQMDetailscqm cqm-ecqm ecqm
374Closing the Referral Loop: Receipt of Specialist ReportProcessCQM, eCQMDetailscqm cqm-ecqm ecqm
386Amyotrophic Lateral Sclerosis (ALS) Patient Care PreferencesProcessCQM, MVPDetailscqm cqm-mvp mvp
392HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation AblationOutcomeCQM, MVPDetailscqm cqm-mvp mvp
393HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or RevisionOutcomeCQM, MVPDetailscqm cqm-mvp mvp
398Optimal Asthma ControlOutcomeCQM, MVPDetailscqm cqm-mvp mvp
400One-Time Screening for Hepatitis C Virus (HCV) for all PatientsProcessCQM, MVPDetailscqm cqm-mvp mvp
404Anesthesiology Smoking AbstinenceProcessCQM, MVPDetailscqm-mvp
409Clinical Outcome Post-Endovascular Stroke TreatmentOutcomeCQM, MVPDetailscqm cqm-mvp mvp
383Adherence to Antipsychotic Medications for Individuals with SchizophreniaProcessCQMDetailscqm
384Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of SurgeryOutcomeCQMDetailscqm
385Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of SurgeryOutcomeCQMDetailscqm
387Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug UsersProcessCQMDetailscqm
389Cataract Surgery: Difference Between Planned and Final RefractionOutcomeCQMDetailscqm
394Immunizations for AdolescentsProcessCQMDetailscqm
395Lung Cancer Reporting (Biopsy/Cytology Specimens)ProcessCQMDetailscqm
396Lung Cancer Reporting (Resection Specimens)ProcessCQMDetailscqm
397Melanoma ReportingProcessCQMDetailscqm
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisProcessCQMDetailscqm
402Tobacco Use and Help with Quitting Among AdolescentsProcessCQMDetailscqm
405Appropriate Follow-up Imaging for Incidental Abdominal LesionsProcessCQMDetailscqm
406Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in PatientsProcessCQMDetailscqm
413Door to Puncture Time for Endovascular Stroke TreatmentProcessCQM, MVPDetailscqm cqm-mvp mvp
415Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderProcessCQM, MVPDetailscqm cqm-mvp mvp
419Overuse of Imaging for the Evaluation of Primary HeadacheProcessCQM, MVPDetailscqm cqm-mvp mvp
424Perioperative Temperature ManagementOutcomeCQM, MVPDetailscqm cqm-mvp mvp
430Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingProcessCQM, MVPDetailscqm cqm-mvp mvp
441Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)ProcessCQM, MVPDetailscqm cqm-mvp mvp
410Psoriasis: Clinical Response to Systemic MedicationsOutcomeCQMDetailscqm
416Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 YearsProcessCQMDetailscqm
420Varicose Vein Treatment with Saphenous Ablation: Outcome SurveyOutcomeCQMDetailscqm
421Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for RemovalProcessCQMDetailscqm
422Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract InjuryProcessCQMDetailscqm
432Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse RepairOutcomeCQMDetailscqm
433Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse RepairOutcomeCQMDetailscqm
439Age Appropriate Screening ColonoscopyProcessCQMDetailscqm
440Skin Cancer: Biopsy Reporting Time – Pathologist to ClinicianProcessCQMDetailscqm
443Non-Recommended Cervical Cancer Screening in Adolescent FemalesProcessCQMDetailscqm
445Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)OutcomeCQMDetailscqm
448Appropriate Workup Prior to Endometrial AblationProcessCQMDetailscqm
450Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast CancerProcessCQM, MVPDetailscqm cqm-mvp mvp
451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
452Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal AntibodiesProcessCQM, MVPDetailscqm cqm-mvp mvp
453Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)ProcessCQM, MVPDetailscqm cqm-mvp mvp
457Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)OutcomeCQM, MVPDetailscqm cqm-mvp mvp
463Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)ProcessCQM, MVPDetailscqm cqm-mvp mvp
470Functional Status After Primary Total Knee ReplacementOutcomeCQM, MVPDetailscqm cqm-mvp mvp
477Multimodal Pain ManagementProcessCQM, MVPDetailscqm cqm-mvp mvp
489Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) TherapyProcessCQM, MVPDetailscqm cqm-mvp mvp
459Back Pain After Lumbar SurgeryOutcomeCQMDetailscqm
461Leg Pain After Lumbar SurgeryOutcomeCQMDetailscqm
464Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate UseProcessCQMDetailscqm
465Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian ArteriesProcessCQMDetailscqm
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)ProcessCQMDetailscqm
471Functional Status After Lumbar SurgeryOutcomeCQMDetailscqm
478Functional Status Change for Patients with Neck ImpairmentsOutcomeCQMDetailscqm
486Dermatitis – Improvement in Patient-Reported Itch SeverityOutcomeCQMDetailscqm
485Psoriasis – Improvement in Patient-Reported Itch SeverityOutcomeCQMDetailscqm
487Screening for Social Drivers of HealthProcessCQMDetailscqm
488Kidney Health EvaluationProcessCQMDetailscqm cqm-ecqm ecqm
493Adult Immunization StatusProcessCQM, MVPDetailscqm cqm-mvp mvp
490Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint InhibitorsProcessCQMDetailscqm
491Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaProcessCQMDetailscqm
024Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and OlderProcessCQM, MVPDetailscqm cqm-mvp mvp
222Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaOutcomeCQMDetailscqm
391Follow-up After Hospitalization for Mental Illness (FUH)ProcessCQMDetailscqm
418Osteoporosis Management in Women Who Had a FractureOutcomeCQMDetailscqm
438Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseProcessCQM, eCQM, MVPDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp ecqm ecqm-mvp mvp
HM7Functional Status Change for Patients with Vestibular DysfunctionOutcomeQCDRDetailsqcdr
IROMS11Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCIDOutcomeQCDRDetailsqcdr
IROMS12Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with knee injury painOutcomeQCDRDetailsqcdr
IROMS13Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCIDOutcomeQCDRDetailsqcdr
IROMS14Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injuryOutcomeQCDRDetailsqcdr
IROMS15/KEET01Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI)OutcomeQCDRDetailsqcdr
IROMS16Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injuryOutcomeQCDRDetailsqcdr
IROMS17Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) scoreOutcomeQCDRDetailsqcdr
IROMS18Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with low back painOutcomeQCDRDetailsqcdr
IROMS19Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCIDOutcomeQCDRDetailsqcdr
IROMS20Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injuryOutcomeQCDRDetailsqcdr
MBHR01Use of Anxiety SeverityProcessQCDRDetailsqcdr
MBHR02Anxiety Response at 6-monthsOutcomeQCDRDetailsqcdr
MBHR03Pain Interference Response utilizing PROMISOutcomeQCDRDetailsqcdr
MBHR05Monitoring for psychosocial problems among children and youthOutcomeQCDRDetailsqcdr
MBHR07Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and ChildrenOutcomeQCDRDetailsqcdr
MBHR08Alcohol Use Disorder Outcome ResponseOutcomeQCDRDetailsqcdr
MBHR09Outcome monitoring of ADHD functional impairment in children and youthOutcomeQCDRDetailsqcdr
MBHR10Symptom Improvement in adults with ADHDOutcomeQCDRDetailsqcdr
MBHR11Cognitive Assessment with Counseling on Safety and Potential RiskProcessQCDRDetailsqcdr
AQI48Patient-Reported Experience with AnesthesiaOutcomeQCDR, MVPDetailsmvp qcdr qcdr-mvp
AQI69Intraoperative Antibiotic RedosingProcessQCDR, MVPDetailsmvp qcdr qcdr-mvp
ECPR46Avoidance of Opiate Prescriptions for Low Back Pain or MigrainesProcessQCDR, MVPDetailsmvp qcdr qcdr-mvp
MBHR18Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of ResultsProcessQCDRDetailsqcdr
MBHR13Social Role Functioning Assessment utilizing PROMIS Adult Ability to Participate in Social Roles and ActivitiesProcessQCDRDetailsqcdr
MBHR14Sleep Quality Sleep Response at 3-monthsOutcomeQCDRDetailsqcdr
MBHR15Consideration of Cultural-Linguistic and Demographic Factors in Cognitive AssessmentProcessQCDRDetailsqcdr
MBHR16Comprehensive Cognitive Assessment Assists with Differential DiagnosisProcessQCDRDetailsqcdr
ACEP59Chest Pain: Avoidance of admission for adult patients with low-risk chest painOutcomeQCDRDetailsqcdr
AQI72Perioperative Anemia ManagementProcessQCDRDetailsqcdr
AQI73Prevention of Arterial Line-Related Bloodstream InfectionsProcessQCDRDetailsqcdr
ECPR39Avoid Head CT for Patients with Uncomplicated SyncopeProcessQCDRDetailsqcdr
ECPR51Discharge Prescription of Naloxone after Opioid Poisoning or OverdoseProcessQCDRDetailsqcdr
ECPR52Appropriate Treatment of Psychosis and Agitation in the Emergency DepartmentProcessQCDRDetailsqcdr
ECPR55Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute PainProcessQCDRDetailsqcdr
ECPR56Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid TreatmentProcessQCDRDetailsqcdr
HCPR16Physicians Orders for Life-Sustaining Treatment (POLST)ProcessQCDRDetailsqcdr
HCPR17Pressure Ulcers -Risk Assessment and Plan of CareProcessQCDRDetailsqcdr
HCPR20Clostridium Difficile- Risk Assessment and Plan of CareProcessQCDRDetailsqcdr
HCPR23Avoidance of Echocardiogram and Carotid Ultrasound for SyncopeProcessQCDRDetailsqcdr
HCPR24Appropriate Utilization of Vancomycin for CellulitisProcessQCDRDetailsqcdr
483Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)OutcomeCQMDetailscqm
304Cataracts: Patient Satisfaction within 90 Days Following Cataract SurgeryOutcomeCQMDetailscqm
303Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryOutcomeCQMDetailscqm
482Hemodialysis Vascular Access: Practitioner Level Long-term Catheter RateOutcomeCQMDetailscqm
110Preventive Care and Screening: Influenza ImmunizationProcessDetailscqm cqm-ecqm cqm-ecqm-mvp cqm-mvp mvp

Licenses are available for the 2023 reporting year.