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 
