2021 MIPS Quality Measures

For information on any of the below measure categories, select the given titles to see a more detailed list.

See Quality measures for other reporting years here.

ALL QUALITY MEASURES: 2021

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
009Anti-Depressant Medication ManagementnoProcessPercentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)View
262Image Confirmation of Successful Excision of Image-Localized Breast LesionyesProcessImage confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsyView
303Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryyesPatient Reported OutcomePercentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function surveyView
304Cataracts: Patient Satisfaction within 90 Days Following Cataract SurgeryyesPatient Engagement/ExperiencePercentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care SurveyView
107Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentnoProcessPercentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedView
239Weight Assessment and Counseling for Nutrition and Physical Activity for Children and AdolescentsnoProcessPercentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. • Percentage of patients with height, weight, and body mass index (BMI) percentile documentation • Percentage of patients with counseling for nutrition • Percentage of patients with counseling for physical activityView
240Childhood Immunization StatusnoProcessPercentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthdayView
281Dementia: Cognitive AssessmentnoProcessPercentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month periodView
305Initiation and Engagement of Alcohol and Other Drug Dependence TreatmentnoProcessPercentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visitView
309Cervical Cancer ScreeningnoProcessPercentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 yearsView
310Chlamydia Screening for WomennoProcessPercentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement periodView
318Falls: Screening for Future Fall RiskyesProcessPercentage of patients 65 years of age and older who were screened for future fall risk during the measurement periodView
321CAHPS for MIPS Clinician/Group SurveyyesSurveyThe Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: • Getting timely care, appointments, and information;
• How well providers Communicate;
• Patient’s Rating of Provider;
• Access to Specialists;
• Health Promotion & Education;
• Shared Decision Making;
• Health Status/Functional Status;
• Courteous and Helpful Office Staff;
• Care Coordination; and
• Stewardship of Patient Resources
View
366Follow-Up Care for Children Prescribed ADHD Medication (ADD)noProcessPercentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase endedView
375Functional Status Assessment for Total Knee ReplacementyesProcessPercentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgeryView
376Functional Status Assessment for Total Hip ReplacementyesProcessPercentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgeryView
377Functional Status Assessments for Congestive Heart FailureyesProcessPercentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessmentsView
378Children Who Have Dental Decay or CavitiesyesOutcomePercentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement periodView
379Primary Caries Prevention Intervention as Offered by Primary Care Providers, including DentistsnoProcessPercentage of children, age 0-20 years, who received a fluoride varnish application during the measurement periodView
382Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentyesProcessPercentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide riskView
462Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation TherapynoProcessPatients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater (indicated by HCPCS code) and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADTView
472Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureyesProcessPercentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.View
475HIV ScreeningnoProcessPercentage of patients 15-65 years of age who have been tested for human immunodeficiency virus (HIV).View
476International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiayesPatient Reported OutcomePercentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.View
051Chronic Obstructive Pulmonary Disease (COPD): Spirometry EvaluationnoProcessPercentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documentedView
001Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)yeseCQM/CQMPercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.View
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)noProcessPercentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital dischargeView
006Coronary Artery Disease (CAD): Antiplatelet TherapynoProcessPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrelView
007Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)noProcessPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy.View
008Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)noProcessPercentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital dischargeView
014Age-Related Macular Degeneration (AMD): Dilated Macular ExaminationnoProcessPercentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance periodView
019Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareyesProcessPercentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 monthsView
021Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation CephalosporinyesProcessPercentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxisView
023Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)yesProcessPercentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end timeView
024Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and OlderyesProcessPercentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communicationView
039Screening for Osteoporosis for Women Aged 65-85 Years of AgenoProcessPercentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosisView
044Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG SurgerynoProcessPercentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incisionView
047Advance Care PlanyesProcessPercentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care planView
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OldernoProcessPercentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 monthsView
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderyesProcessPercentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 monthsView
052Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator TherapynoProcessPercentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilatorView
065Appropriate Treatment for Children with Upper Respiratory Infection (URI)yesProcessPercentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episodeView
066Appropriate Testing for Children with PharyngitisyesProcessPercentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episodeView
067Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone MarrownoProcessPercentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrowView
070Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow CytometrynoProcessPercentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chartView
076Prevention of Central Venous Catheter (CVC) - Related Bloodstream InfectionsyesProcessPercentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followedView
093Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseyesProcessPercentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapyView
102Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer PatientsyesProcessPercentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancerView
104Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate CancernoProcessPercentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostateView
110Preventive Care and Screening: Influenza ImmunizationnoProcessPercentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunizationView
111Pneumococcal Vaccination Status for Older AdultsnoProcessPercentage of patients 65 years of age and older who have ever received a pneumococcal vaccineView
112Breast Cancer ScreeningnoProcessPercentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.View
113Colorectal Cancer ScreeningnoProcessPercentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.View
116Avoidance of Antibiotic Treatment in Adults With Acute BronchitisyesProcessThe percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescriptionView
117Diabetes: Eye ExamnoProcessPercentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.View
118Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)noProcessPercentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapyView
119Diabetes: Medical Attention for NephropathynoProcessThe percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.View
126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationnoProcessPercentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 monthsView
127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of FootwearnoProcessPercentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizingView
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlannoProcessPercentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
View
130Documentation of Current Medications in the Medical RecordyesProcessPercentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administrationView
134Preventive Care and Screening: Screening for Depression and Follow-Up PlannoeCQM/CQMPercentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screenView
137Melanoma: Continuity of Care – Recall SystemyesStructurePercentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointmentView
138Melanoma: Coordination of CareyesProcessPercentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosisView
141Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of CareyesOutcomePercentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance periodView
143Oncology: Medical and Radiation – Pain Intensity QuantifiedyesProcessPercentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.View
144Oncology: Medical and Radiation – Plan of Care for Moderate to Severe PainyesProcessPercentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinicianView
145Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using FluoroscopyyesProcessFinal reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)View
147Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone ScintigraphyyesProcessPercentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performedView
154Falls: Risk AssessmentyesProcessPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 monthsView
155Falls: Plan of CareyesProcessPercentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 monthsView
164Coronary Artery Bypass Graft (CABG): Prolonged IntubationyesOutcomePercentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation 24 hours.View
167Coronary Artery Bypass Graft (CABG): Postoperative Renal FailureyesOutcomePercentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.View
168Coronary Artery Bypass Graft (CABG): Surgical Re-ExplorationyesOutcomePercentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.View
176Rheumatoid Arthritis (RA): Tuberculosis ScreeningnoProcessPercentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who havedocumentation of a tuberculosis (TB) screening performed and results interpreted within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)View
177Rheumatoid Arthritis (RA): Periodic Assessment of Disease ActivitynoProcessPercentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity at ≥50% of encounters for RA for each patient during the measurement yearView
178Rheumatoid Arthritis (RA): Functional Status AssessmentnoProcessPercentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.View
180Rheumatoid Arthritis (RA): Glucocorticoid ManagementnoProcessPercentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.View
181Elder Maltreatment Screen and Follow-Up PlanyesProcessPercentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screenView
182Functional Outcome AssessmentyesProcessPercentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficienciesView
185Colonoscopy Interval for Patients with a History of Adenomatous Polyps– Avoidance of Inappropriate UseyesProcessPercentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopyView
187Stroke and Stroke Rehabilitation: Thrombolytic TherapynoProcessPercentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known wellView
191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryyesOutcomePercentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.View
195Radiology: Stenosis Measurement in Carotid Imaging ReportsnoProcessPercentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurementView
205HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and SyphilisnoProcessPercentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infectionView
217Functional Status Change for Patients with Knee ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
218Functional Status Change for Patients with Hip ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
219Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the Foot/Ankle FS patient- reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
220Functional Status Change for Patients with Low Back ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
221Functional Status Change for Patients with Shoulder ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
222Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).View
225Radiology: Reminder System for Screening MammogramsyesStructurePercentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogramView
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionnoProcessPercentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.View
236Controlling High Blood PressureyeseCQM/CQMPercentage of patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period.View
238Use of High-Risk Medications in the ElderlyyesProcessPercentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication 2) Percentage of patients who were ordered at least two of the same high-risk medicationView
243Cardiac Rehabilitation Patient Referral from an Outpatient SettingyesProcessPercentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR programView
249Barrett’s EsophagusnoProcessPercentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasiaView
250Radical Prostatectomy Pathology ReportingnoProcessPercentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin statusView
254Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal PainnoProcessPercentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy locationView
258Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)yesOutcomePercent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)View
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)yesOutcomePercent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)View
260Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)yesOutcomePercent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2View
264Sentinel Lymph Node Biopsy for Invasive Breast CancernoProcessThe percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedureView
265Biopsy Follow-UpyesProcessPercentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patientView
261Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessyesProcessPercentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.View
268Epilepsy: Counseling for Women of Childbearing Potential with EpilepsynoProcessAll female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a yearView
275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapynoProcessPercentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapyView
277Sleep Apnea: Severity Assessment at Initial DiagnosisnoProcessPercentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosisView
279Sleep Apnea: Assessment of Adherence to Positive Airway Pressure TherapynoProcessPercentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measuredView
282Dementia: Functional Status AssessmentnoProcessPercentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 monthsView
283Dementia Associated Behavioral and Psychiatric Symptoms Screening and ManagementnoProcessPercentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 monthsView
286Dementia: Safety Concern Screening and Follow-Up for Patients with DementiayesProcessPercentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resourcesView
288Dementia: Education and Support of Caregivers for Patients with DementiayesProcessPercentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 monthsView
290Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s DiseasenoProcessPercentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms in the past 12 monthsView
291Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's DiseasenoProcessPercentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 monthsView
293Parkinson’s Disease: Rehabilitative Therapy OptionsyesProcessPercentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 monthsView
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentednoProcessPercentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicatedView
320Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsyesProcessPercentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy reportView
322Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery PatientsyesEfficiencyPercentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission periodView
323Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)yesEfficiencyPercentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom statusView
324Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk PatientsyesEfficiencyPercentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessmentView
326Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapynoProcessPercentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement periodView
331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)yesProcessPercentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptomsView
332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)yesProcessPercentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosisView
335Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse)yesOutcomePercentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication.View
336Maternity Care: Post-Partum Follow-Up and Care CoordinationyesProcessPercentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care within 8 weeks of giving birth and who received a breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and updateView
337Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response ModifiernoProcessPercentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive testView
338HIV Viral Load SuppressionyesOutcomeThe percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement yearView
340HIV Medical Visit FrequencyyesProcessPercentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visitsView
342Pain Brought Under Control Within 48 HoursyesOutcomePatients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hoursView
344Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)yesOutcomePercent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2View
350Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) TherapyyesProcessPercentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedureView
351Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationyesProcessPercentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)View
354Anastomotic Leak InterventionyesOutcomePercentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgeryView
355Unplanned Reoperation within the 30 Day Postoperative PeriodyesOutcomePercentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative periodView
356Unplanned Hospital Readmission within 30 Days of Principal ProcedureyesOutcomePercentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedureView
357Surgical Site Infection (SSI)yesOutcomePercentage of patients aged 18 years and older who had a surgical site infection (SSI)View
358Patient-Centered Surgical Risk Assessment and CommunicationyesProcessPercentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeonView
360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesyesProcessPercentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current studyView
364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesyesProcessPercentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians)View
370Depression Remission at Twelve MonthsyesOutcomeThe percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.View
374Closing the Referral Loop: Receipt of Specialist ReportyesProcessPercentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referredView
383Adherence to Antipsychotic Medications For Individuals with SchizophreniayesIntermediate OutcomePercentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)View
384Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of SurgeryyesOutcomePatients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgeryView
385Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of SurgeryyesOutcomePatients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eyeView
386Amyotrophic Lateral Sclerosis (ALS) Patient Care PreferencesyesProcessPercentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annuallyView
387Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug UsersnoProcessPercentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting periodView
389Cataract Surgery: Difference Between Planned and Final RefractionyesOutcomePercentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refractionView
391Follow-Up After Hospitalization for Mental Illness (FUH)yesProcessThe percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner.View
392HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation AblationyesOutcomeRate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender: • Submission Age Criteria 1: Females 18-64 years of age • Submission Age Criteria 2: Males 18-64 years of age • Submission Age Criteria 3: Females 65 years of age and older • Submission Age Criteria 4: Males 65 years of age and olderView
393HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or RevisionyesOutcomeInfection rate following CIED device implantation, replacement, or revisionView
394Immunizations for AdolescentsnoProcessThe percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.View
395Lung Cancer Reporting (Biopsy/Cytology Specimens)yesProcessPathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology reportView
396Lung Cancer Reporting (Resection Specimens)yesProcessPathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic typeView
397Melanoma ReportingyesProcessPathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rateView
398Optimal Asthma ControlyesOutcomeComposite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbationView
400One-Time Screening for Hepatitis C Virus (HCV) for Patients at RisknoProcessPercentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infectionView
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisnoProcessPercentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission periodView
402Tobacco Use and Help with Quitting Among AdolescentsnoProcessThe percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco userView
404Anesthesiology Smoking AbstinenceyesIntermediate OutcomeThe percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedureView
405Appropriate Follow-up Imaging for Incidental Abdominal LesionsyesProcessPercentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow-up imaging recommended based on radiological findings.View
406Appropriate Follow-up Imaging for Incidental Thyroid Nodules in PatientsyesProcessPercentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommendedView
409Clinical Outcome Post Endovascular Stroke TreatmentyesOutcomePercentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke interventionView
410Psoriasis: Clinical Response to Systemic MedicationsyesOutcomePercentage of psoriasis vulgaris patients receiving systemic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatmentView
413Door to Puncture Time for Endovascular Stroke TreatmentyesIntermediate OutcomePercentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hoursView
415Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderyesEfficiencyPercentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CTView
416Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 YearsyesEfficiencyPercentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injuryView
418Osteoporosis Management in Women Who Had a FracturenoProcessThe percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture.View
419Overuse of Imaging for the Evaluation of Primary HeadacheyesProcessPercentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not presentView
420Varicose Vein Treatment with Saphenous Ablation: Outcome SurveyyesPatient Reported OutcomePercentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatmentView
421Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for RemovalnoProcessPercentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attemptsView
422Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract InjuryyesProcessPercentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapseView
424Perioperative Temperature ManagementyesOutcomePercentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end timeView
425Photodocumentation of Cecal IntubationnoProcessThe rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examinationView
429Pelvic Organ Prolapse: Preoperative Screening for Uterine MalignancyyesProcessPercentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapseView
430Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination TherapyyesProcessPercentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperativelyView
431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingnoProcessPercentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol userView
432Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse RepairyesOutcomePercentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgeryView
433Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse RepairyesOutcomePercentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgeryView
434Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse RepairyesOutcomePercentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgeryView
436Radiation Consideration for Adult CT: Utilization of Dose Lowering TechniquesnoProcessPercentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction techniqueView
438Statin Therapy for the Prevention and Treatment of Cardiovascular DiseasenoProcessPercentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the performance period.View
439Age Appropriate Screening ColonoscopyyesEfficiencyThe percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31View
440Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to ClinicianyesProcessPercentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologistView
441Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)yesIntermediate OutcomeThe IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator.View
443Non-Recommended Cervical Cancer Screening in Adolescent FemalesyesProcessThe percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancerView
444Medication Management for People with AsthmayesProcessThe percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment periodView
445Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)yesOutcomePercent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.View
448Appropriate Workup Prior to Endometrial AblationyesProcessPercentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.View
450Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant ChemotherapyyesProcessProportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab.View
451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody TherapynoProcessPercentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performedView
452Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal AntibodiesyesProcessPercentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodiesView
453Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)yesProcessPercentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.View
455Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)yesOutcomePercentage of patients who died from cancer admitted to the ICU in the last 30 days of life.View
457Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)yesOutcomePercentage of patients who died from cancer, and admitted to hospice and spent less than 3 days thereView
459Average Change in Back Pain Following Lumbar Discectomy/LaminotomyyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.View
460Average Change in Back Pain Following Lumbar FusionyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively * hereafter referred to as VAS Pain.View
461Average Change in Leg Pain Following Lumbar Discectomy and/or LaminotomyyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.View
463Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)yesProcessPercentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperativelyView
464Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate UseyesProcessPercentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobialsView
465Uterine Artery Embolization Technique: Documenttion of Angigraphic Endpoints and Interrogation of Ovarian ArteriesyesProcessThe percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteriesView
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)yesProcessPercentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatmentView
469Average Change in Functional Status Following Lumbar Fusion SurgeryyesPatient Reported OutcomeFor patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a)* at one year (9 to 15 months) postoperatively * hereafter referred to as ODI.View
470Average Change In Functional Status Following Total Knee Replacement SurgeryyesPatient Reported OutcomeFor patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) at one year (9 to 15 months) postoperatively.View
471Average Change in Functional Status Following Lumbar Discectomy/Laminotomy SurgeryyesPatient Reported OutcomeFor patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively * hereafter referred to as ODI.View
473Average Change in Leg Pain Following Lumbar Fusion SurgeryyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively
* hereafter referred to as VAS Pain.
View
477Multimodal Pain ManagementyesProcessPercentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine. Percentage of members 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; and pneumococcal.View
478Functional Status Change for Patients with Neck ImpairmentsyesPatient Reported OutcomeThis is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk- adjusted change in functional status (FS) for patients aged 14+ with neck impairments. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality. *The Neck FS PROM is an item-response theory-based computer adaptive test (CAT). In addition to the CAT version, which provides for reduced patient response burden, it is available as a 10-item short form (static/paper-pencil).View