2022 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.

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
3762022 MIPS Measure #376: Functional Status Assessment for Total Hip ReplacementeCQMPercentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgeryView
3752022 MIPS Measure #375: Functional Status Assessment for Total Knee ReplacementeCQMPercentage 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
4752022 MIPS Measure #475: HIV ScreeningeCQMPercentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIVView
4762022 MIPS Measure #476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiaeCQMPercentage 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 pointsView
2392022 MIPS Measure #239: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/AdolescentseCQMPercentage 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.View
3092022 MIPS Measure #309: Cervical Cancer ScreeningeCQMPercentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:View
3102022 MIPS Measure #310: Chlamydia Screening for WomeneCQMPercentage 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
3052022 MIPS Measure #305: Initiation and Engagement of Alcohol and Other Drug Dependence TreatmenteCQMPercentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.View
4622022 MIPS Measure # 462: Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapyeCQMPatients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater 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 ADT.View
1072022 MIPS Measure #107: Adult Major Depressive Disorder (MDD): Suicide Risk AssessmenteCQMAll patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visitView
3182022 MIPS Measure # 318: Falls: Screening for Future Fall RiskeCQMPercentage of patients 65 years of age and older who were screened for future fall risk during the measurement periodView
3782022 MIPS Measure #378: Children Who Have Dental Decay or CavitieseCQMPercentage of children, 6 months - 20 years of age at the start of the measurement period, who have had tooth decay or cavities during the measurement periodView
3792022 MIPS Measure #379: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including DentistseCQMPercentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement periodView
3822022 MIPS Measure #382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmenteCQMPercentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide riskView
2812022 MIPS Measure #281: Dementia: Cognitive AssessmenteCQMPercentage 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
4722022 MIPS Measure #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureeCQMPercentage 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 periodView
3662022 MIPS Measure #366: Follow-Up Care for Children Prescribed ADHD Medication (ADD)eCQMPercentage 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.View
IROMS112022 QCDR Measure: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in 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 MCIDYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported.View
IROMS122022 QCDR Measure: Failure 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 of patients with knee injuryYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with knee injury treated during the observation period will be reported.View
IROMS132022 QCDR Measure: Failure to Progress (FTP): Proportion of patients failing to achieve 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 MCIDYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.View
IROMS142022 QCDR Measure: Failure 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 of patients with hip, leg, or ankle (lower extremity except knee) injuryYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injury treated during the observation period will be reported.View
IROMS152022 QCDR Measure: Failure 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 their validated Neck Disability Index (NDI) scoreYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of seven and ½ (7.5) points or more improvement in the NDI change score for patients with neck pain/injury treated during the observation period will be reported.View
IROMS162022 QCDR Measure: Failure 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 of patients with neck pain/injuryYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported.View
IROMS172022 QCDR Measure: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with low back pain measured via their validated Modified Low Back Pain Disability Questionnaire (MDQ) scoreYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported.View
IROMS182022 QCDR Measure: Failure 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 of patients with low back painYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported.View
IROMS192022 QCDR Measure: Failure 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, or hand injury measured via their validated Disability of the Arm, Shoulder and Hand (DASH) score, Quick Disability of the Arm, Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCIDYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder or hand injury treated during the observation period will be reported.View
IROMS202022 QCDR Measure: Failure 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 of patients with arm, shoulder, or hand injuryYESPatient Reported OutcomeThe proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported.View
HM072022 QCDR Measure: Functional Status Change for Patients with Vestibular DysfunctionYESPatient Reported OutcomePercentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) to indicate functional, emotional, and physical improvement.View
0012022 Measure # 001 Diabetes: Hemoglobin A1c Poor ControlyesIntermediate OutcomePercentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.View
0052022 Measure # 005 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)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
0062022 Measure # 006 Coronary 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
0072022 Measure # 007 Coronary 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
0082022 Measure # 008 Heart 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
0142022 Measure # 014 Age-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
0192022 Measure # 019 Diabetic 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
0242022 Measure # 024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and OlderyesProcessCommunication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and OlderView
0392022 Measure # 039 Screening 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
0472022 Measure # 047 Advance 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
0482022 Measure # 048 Urinary 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
0502022 Measure # 050 Urinary 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
0522022 Measure # 052 Chronic 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 an long-acting inhaled bronchodilatorView
0652022 Measure # 065 Appropriate Treatment for Upper Respiratory Infection (URI)yesProcessPercentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing eventView
0662022 Measure # 066 Appropriate Testing for PharyngitisyesProcessThe percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) testView
0762022 Measure # 076 Prevention 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
0932022 Measure # 093 Acute 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
1022022 Measure # 102 Prostate 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 who did not have a bone scan performed at any time since diagnosis of prostate cancerView
1042022 Measure # 104 Prostate 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
1102022 Measure # 110 Preventive 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
1262022 Measure # 126 Diabetes 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
1272022 Measure # 127 Diabetes 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
1282022 Measure # 128 Preventive 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 encounterView
1302022 Measure # 130 Documentation 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
1342022 Measure # 134 Preventive Care and Screening: Screening for Depression and Follow-Up PlannoProcessPercentage of patients aged 12 years and older screened for depression on the date of the encounter or 14 days prior to 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 eligible encounterView
1552022 Measure # 155 Falls: 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
1112022 Measure # 111 Pneumococcal Vaccination Status for Older AdultsnoProcessPercentage of patients 66 years of age and older who have ever received a pneumococcal vaccineView
1122022 Measure # 112 Breast 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
1132022 Measure # 113 Colorectal Cancer ScreeningnoProcessPercentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.View
1162022 Measure # 116 Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisyesProcessThe percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescriptionView
1172022 Measure # 117 Diabetes: Eye ExamnoProcessPercentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of 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 in any part of 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
1182022 Measure # 118 Coronary 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
1192022 Measure # 119 Diabetes: 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
1372022 Measure # 137 Melanoma: 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:View
1382022 Measure # 138 Melanoma: 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
1412022 Measure # 141 Primary 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
1432022 Measure # 143 Oncology: 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
1442022 Measure # 144 Oncology: Medical and Radiation – Plan of Care for PainyesProcessPercentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address painView
1452022 Measure # 145 Radiology: 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
1472022 Measure # 147 Nuclear 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, MRI, CT, etc.) that were performedView
1812022 Measure # 181 Elder 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
1822022 Measure # 182 Functional 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 deficiencies.View
1642022 Measure # 164 Coronary Artery Bypass Graft (CABG): Prolonged IntubationnoProcessPercentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.View
1672022 Measure # 167 Coronary Artery Bypass Graft (CABG): Postoperative Renal FailurenoProcessPercentage 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
1682022 Measure # 168 Coronary Artery Bypass Graft (CABG): Surgical Re-ExplorationnoProcessPercentage 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
1762022 Measure # 176 Tuberculosis Screening Prior to First Course Biologic TherapynoProcessIf a patient has been newly prescribed a biologic disease-modifying anti-rheumatic drug (DMARD) therapy, then the medical record should indicate TB testing in the preceding 12-month period.View
1772022 Measure # 177 Rheumatoid 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 using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the measurement yearView
1782022 Measure # 178 Rheumatoid 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
1802022 Measure # 180 Rheumatoid 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
1852022 Measure # 185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate UsenoProcessPercentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.View
1872022 Measure # 187 Stroke 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
1912022 Measure # 191 Cataracts: 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
2052022 Measure # 205 HIV/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
2172022 Measure # 217 Functional 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 FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM) . 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 level, 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
2182022 Measure # 218 Functional 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 FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM) . 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 level, 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
2192022 Measure # 219 Functional 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 or lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient- reported outcome measure (PROM). 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 level, 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
2202022 Measure # 220 Functional 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 FOTO Low Back FS patient-reported outcome measure (PROM). 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 level, 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
2212022 Measure # 221 Functional 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 FOTO Shoulder FS patient-reported outcome measure (PROM). 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 level, 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
2222022 Measure # 222 Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsyesPatient Reported OutcomeFunctional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsView
2262022 Measure # 226 Preventive 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 the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco userView
2362022 Measure # 236 Controlling High Blood PressureyesIntermediate OutcomePercentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement periodView
2382022 Measure # 238 Use of High-Risk Medications in Older AdultsyesProcessPercentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug classView
2432022 Measure # 243 Cardiac 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
2492022 Measure # 249 Barrett's EsophagusnoProcessPercentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasiaView
2502022 Measure # 250 Radical 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
2542022 Measure # 254 Ultrasound 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
2582022 Measure # 258 Rate of Open Repair of Small or Moderate Non-Ruptured 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
2592022 Measure # 259 Rate 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)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
2602022 Measure # 260 Rate 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
2612022 Measure # 261 Referral 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
2642022 Measure # 264 Sentinel 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
2652022 Measure # 265 Biopsy Follow-UpyesProcessPercentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.View
2682022 Measure # 268 Epilepsy: Counseling for Women of Childbearing Potential with EpilepsynoProcessPercentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancyView
2752022 Measure # 275 Inflammatory 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
2772022 Measure # 277 Sleep 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
2792022 Measure # 279 Sleep 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
2822022 Measure # 282 Dementia: Functional Status AssessmentnoProcessPercentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.View
2832022 Measure # 283 Dementia 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
2862022 Measure # 286 Dementia: 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
2882022 Measure # 288 Dementia: 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
2902022 Measure # 290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s DiseasenoProcessPercentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for depression, anxiety, apathy, AND psychosis once during the measurement period.View
2912022 Measure # 291 Parkinson’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 once during the measurement period.View
2932022 Measure # 293 Rehabilitative Therapy Referral for Patients with Parkinson’s DiseaseyesProcessPercentage of all patients with a diagnosis of Parkinson’s Disease who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.View
3172022 Measure # 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentednoProcessPercentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.View
3202022 Measure # 320 Appropriate 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 polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy reportView
3222022 Measure # 322 Cardiac 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
3232022 Measure # 323 Cardiac 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
3242022 Measure # 324 Cardiac 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
3262022 Measure # 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapynoProcessPercentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribedView
3312022 Measure # 331 Adult 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
3322022 Measure # 332 Adult 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
3352022 Measure # 335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)yesOutcomePercentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.View
3362022 Measure # 336 Maternity Care: Postpartum Follow-Up and Care CoordinationyesProcessPercentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: 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
3382022 Measure # 338 HIV 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
3402022 Measure # 340 HIV 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
3442022 Measure # 344 Rate 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
3502022 Measure # 350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) TherapyyesProcessPercentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.View
3512022 Measure # 351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationyesProcessPercentage of patients regardless of age undergoing a total knee or total hip 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
3542022 Measure # 354 Anastomotic Leak InterventionyesOutcomePercentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgeryView
3552022 Measure # 355 Unplanned 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
3562022 Measure # 356 Unplanned 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
3572022 Measure # 357 Surgical Site Infection (SSI)yesOutcomePercentage of patients aged 18 years and older who had a surgical site infection (SSI)View
3582022 Measure # 358 Patient-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
3602022 Measure # 360 Optimizing 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
3642022 Measure # 364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesyesProcessPercentage 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
3702022 Measure # 370 Depression 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
3742022 Measure # 374 Closing 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
3832022 Measure # 383 Adherence to Antipsychotic Medications for Individuals with SchizophreniayesIntermediate OutcomePercentage of individuals at least 18 years of age as of the beginning of the performance 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 performance periodView
3842022 Measure # 384 Adult 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
3852022 Measure # 385 Adult 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
3862022 Measure # 386 Amyotrophic 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
3872022 Measure # 387 Annual 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
3892022 Measure # 389 Cataract 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
3912022 Measure # 391 Follow-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 provider.View
3922022 Measure # 392 HRS-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 genderView
3932022 Measure # 393 HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or RevisionyesOutcomeInfection rate following CIED device implantation, replacement, or revisionView
3942022 Measure # 394 Immunizations for AdolescentsnoProcessThe percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.View
3952022 Measure # 395 Lung Cancer Reporting (Biopsy/Cytology Specimens)yesProcessPathology reports based on lung biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type following the International Association for the Study of Lung Cancer (IASLC) guidance or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.View
3962022 Measure # 396 Lung Cancer Reporting (Resection Specimens)yesProcessPathology reports based on lung resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.View
3972022 Measure # 397 Melanoma ReportingyesProcessPathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.View
3982022 Measure # 398 Optimal 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
4002022 Measure # 400 One-Time Screening for Hepatitis C Virus (HCV) for all PatientsnoProcessPercentage 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
4012022 Measure # 401 Hepatitis 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
4022022 Measure # 402 Tobacco 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
4042022 Measure # 404 Anesthesiology Smoking AbstinenceyesIntermediate OutcomeThe percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedureView
4052022 Measure # 405 Appropriate 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:
• Cystic renal lesion that is simple appearing* (Bosniak I or II)
• Adrenal lesion less than or equal to 1.0 cm
• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols
View
4062022 Measure # 406 Appropriate 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
4092022 Measure # 409 Clinical Outcome Post-Endovascular Stroke TreatmentyesOutcomePercentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.View
4102022 Measure # 410 Psoriasis: Clinical Response to Systemic MedicationsyesOutcomePercentage of psoriasis vulgaris patients receiving systemic medication 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
4132022 Measure # 413 Door to Puncture Time for Endovascular Stroke TreatmentyesIntermediate OutcomePercentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.View
4152022 Measure # 415 Emergency 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 clinician who have an indication for a head CTView
4162022 Measure # 416 Emergency 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
4182022 Measure # 418 Osteoporosis 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 fractureView
4192022 Measure # 419 Overuse 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
4202022 Measure # 420 Varicose 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
4212022 Measure # 421 Appropriate Assessment of Retrievable Inferior Vena Cava 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
4222022 Measure # 422 Performing 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
4242022 Measure # 424 Perioperative 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
4252022 Measure # 425 Photodocumentation 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
4302022 Measure # 430 Prevention 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 or intraoperativelyView
4312022 Measure # 431 Preventive 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 12 months AND who received brief counseling if identified as an unhealthy alcohol userView
4322022 Measure # 432 Proportion 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
4332022 Measure # 433 Proportion 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
4362022 Measure # 436 Radiation 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 usedView
4382022 Measure # 438 Statin 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 measurement period:
•All patients who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
•Patients aged ≥ 20 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
•Patients aged 40-75 years with a diagnosis of diabetes
View
4392022 Measure # 439 Age Appropriate Screening ColonoscopyyesEfficiencyThe percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31View
4402022 Measure # 440 Skin Cancer: Biopsy Reporting Time – Pathologist to ClinicianyesProcessPercentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (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
4412022 Measure # 441 Ischemic 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
4432022 Measure # 443 Non-Recommended Cervical Cancer Screening in Adolescent FemalesyesProcessThe percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancerView
4452022 Measure # 445 Risk-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
4482022 Measure # 448 Appropriate 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
4502022 Measure # 450 Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast CanceryesProcessPercentage of female patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiatedView
4512022 Measure # 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 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
4522022 Measure # 452 Patients 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
4532022 Measure # 453 Percentage 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
4552022 Measure # 455 Percentage 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
4572022 Measure # 457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)yesOutcomeProportion of patients who died from cancer, and admitted to hospice and spent less than 3 days thereView
4592022 Measure # 459 Back Pain After 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
4602022 Measure # 460 Back Pain After 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
4612022 Measure # 461 Leg Pain After Lumbar Discectomy/ 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) postoperativelyView
4632022 Measure # 463 Prevention 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
4642022 Measure # 464 Otitis Media with Effusion: Systemic AntimicrobialsyesProcessPercentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobialsView
4652022 Measure # 465 Uterine Artery Embolization Technique: Documentation of Angiographic 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
4682022 Measure # 468 Continuity 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
4692022 Measure # 469 Functional Status After Lumbar FusionyesPatient 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 an improvement 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 ODIView
4702022 Measure # 470 Functional Status After Primary Total Knee ReplacementyesPatient 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) or a 71 or greater on the KOOS, JR. tool at one year (9 to 15 months) postoperativelyView
4712022 Measure # 471 Functional Status After Lumbar Discectomy/LaminectomyyesPatient 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 an improvement 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 ODIView
4732022 Measure # 473 Leg Pain After Lumbar FusionyesPatient 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
4772022 Measure # 477 Multimodal Pain ManagementyesProcessPercentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicineView
4782022 Measure # 478 Functional Status Change for Patients with Neck ImpairmentsyesPatient Reported OutcomeA patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient-reported outcome measure (PROM). 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 level, 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/paper-pencil).View