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 | |
|---|---|---|---|---|---|---|---|
| 024 | 2022 Measure # 024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | yes | Process | Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | Details | ||
| 039 | 2022 Measure # 039 Screening for Osteoporosis for Women Aged 65-85 Years of Age | no | Process | Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis | Details | ||
| 047 | 2022 Measure # 047 Advance Care Plan | yes | Process | Percentage 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 plan | Details | ||
| 048 | 2022 Measure # 048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | no | Process | Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months | Details | ||
| 110 | 2022 Measure # 110 Preventive Care and Screening: Influenza Immunization | no | Process | Percentage 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 immunization | Details | ||
| 001 | 2022 Measure # 001 Diabetes: Hemoglobin A1c Poor Control | yes | Intermediate Outcome | Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. | Details | ||
| 126 | 2022 Measure # 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | no | Process | Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months | Details | ||
| 155 | 2022 Measure # 155 Falls: Plan of Care | yes | Process | Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months | Details | ||
| 134 | 2022 Measure # 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan | no | Process | Percentage 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 encounter | Details | ||
| 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 | ||
| 128 | 2022 Measure # 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | no | Process | Percentage 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 | Details | ||
| 119 | 2022 Measure # 119 Diabetes: Medical Attention for Nephropathy | no | Process | The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period. | Details | ||
| 116 | 2022 Measure # 116 Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | yes | Process | The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription | Details | ||
| 113 | 2022 Measure # 113 Colorectal Cancer Screening | no | Process | Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer. | Details | ||
| 112 | 2022 Measure # 112 Breast Cancer Screening | no | Process | Percentage 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. | Details | ||
| 111 | 2022 Measure # 111 Pneumococcal Vaccination Status for Older Adults | no | Process | Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine | Details | ||
| 182 | 2022 Measure # 182 Functional Outcome Assessment | yes | Process | Percentage 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. | 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 | ||
| 374 | 2022 Measure # 374 Closing the Referral Loop: Receipt of Specialist Report | yes | Process | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Details | ||
| 402 | 2022 Measure # 402 Tobacco Use and Help with Quitting Among Adolescents | no | Process | The 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 user | Details | ||
| 431 | 2022 Measure # 431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | no | Process | Percentage 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 user | Details | ||
| 438 | 2022 Measure # 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | no | Process | Percentage 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 | Details | ||
| 477 | 2022 Measure # 477 Multimodal Pain Management | yes | Process | Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine | Details |
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