CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.
| Quality Id | Measure Name | High Priority | Measure Type | Measure Description | hf:tax:specialty_measure_sets | hf:tax:collection_types | |
|---|---|---|---|---|---|---|---|
| 130 | 2022 Measure # 130 Documentation of Current Medications in the Medical Record | yes | Process | Percentage 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 administration | Details | ||
| 187 | 2022 Measure # 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy | no | Process | Percentage 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 well | Details | ||
| 226 | 2022 Measure # 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | no | Process | Percentage 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 user | Details | ||
| 260 | 2022 Measure # 260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | yes | Outcome | Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 | Details | ||
| 409 | 2022 Measure # 409 Clinical Outcome Post-Endovascular Stroke Treatment | yes | Outcome | Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention. | Details | ||
| 413 | 2022 Measure # 413 Door to Puncture Time for Endovascular Stroke Treatment | yes | Intermediate Outcome | Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less. | Details | ||
| 459 | 2022 Measure # 459 Back Pain After Lumbar Discectomy/Laminotomy | yes | Patient Reported Outcome | For 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. | Details | ||
| 460 | 2022 Measure # 460 Back Pain After Lumbar Fusion | yes | Patient Reported Outcome | For 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. | Details | ||
| 461 | 2022 Measure # 461 Leg Pain After Lumbar Discectomy/ Laminotomy | yes | Patient Reported Outcome | For 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 | Details | ||
| 469 | 2022 Measure # 469 Functional Status After Lumbar Fusion | yes | Patient Reported Outcome | For 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 ODI | Details | ||
| 471 | 2022 Measure # 471 Functional Status After Lumbar Discectomy/Laminectomy | yes | Patient Reported Outcome | For 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 ODI | Details | ||
| 473 | 2022 Measure # 473 Leg Pain After Lumbar Fusion | yes | Patient Reported Outcome | For 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. | Details |
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