Quality
PI
IA
Cost
Quality Measures
For 2024, the Quality Measures category will contribute to 30% of the MIPS Final Score. Quality category performance will be based on the full calendar year (January 1st – December 31st).
Please visit https://qpp.cms.gov/about/resource-library for a complete list of the 2024 MIPS Quality measures. For 2024, FIGmd will be supporting all the CQMs and eCQMs approved by CMS.
#001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
Description:
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#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)
Description:
Percentage 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 discharge.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#006 Coronary Artery Disease (CAD): Antiplatelet Therapy
Description:
Percentage 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 clopidogrel.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#007 Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF = 40%)
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Description:
Percentage 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 discharge.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#009 Anti-Depressant Medication Management
Description:
Percentage 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).
-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Description:
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Description:
Percentage 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 during the performance period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#024 Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older
Description:
Percentage 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 communication.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#039 Screening for Osteoporosis for Women Aged 65-85 Years of Age
Description:
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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#047 Advance Care Plan
Description:
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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Description:
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#050 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Description:
Percentage 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 months.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#052 Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy
Description:
Percentage of patients aged 18 years and older with a diagnosis of COPD with a documented FEV1/FVC < 70% measured by spirometry, who are symptomatic, and were prescribed a long-acting inhaled bronchodilator.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#065 Appropriate Treatment for Upper Respiratory Infection (URI)
Description:
Percentage 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 order.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#066 Appropriate Testing for Pharyngitis
Description:
The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order on or within 3 days after the episode date and a group A Streptococcus (Strep) test in the seven-day period from three days prior to the episode date through three days after the episode date.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Description:
Percentage 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 cancer.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
Description:
Percentage 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 prostate.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#112 Breast Cancer Screening (For MVP Only)
Description:
Percentage of women 40 - 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#113 Colorectal Cancer Screening (For MVP Only)
Description:
Percentage of patients 45-75 years of age who had appropriate screening for colorectal cancer-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#116 Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
Description:
The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#117 Diabetes: Eye Exam
Description:
Percentage 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 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 during the measurement period or in the 12 months prior to the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF = 40%)
Description:
Percentage 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 therapy.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation
Description:
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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear
Description:
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (For MVP Only)
Description:
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if the most recent BMI was outside of normal parameters.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#130 Documentation of Current Medications in the Medical Record
Description:
Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Description:
Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 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 or up to two days after the date of the qualifying encounter.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#137 Melanoma: Continuity of Care - Recall System
Description:
Percentage 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 appointment.
-
NQS Domain:
- -
Measure Type:
Structure -
High Priority Measure:
Yes
#141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
Description:
Percentage 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 20% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 20% from the pre-intervention level, a plan of care was documented within the 12 month performance period.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#143 Oncology: Medical and Radiation - Pain Intensity Quantified
Description:
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#144 Oncology: Medical and Radiation - Plan of Care for Pain
Description:
Percentage 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 pain.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#145 Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy
Description:
Final reports for procedures using fluoroscopy that document radiation exposure indices.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#155 Falls: Plan of Care
Description:
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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Description:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
Description:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#176 Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy
Description:
If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Description:
Percentage 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 year.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#178 Rheumatoid Arthritis (RA): Functional Status Assessment
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#180 Rheumatoid Arthritis (RA): Glucocorticoid Management
Description:
Percentage 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 >5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#181 Elder Maltreatment Screen and Follow-Up Plan
Description:
Percentage of patients aged 60 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 screen.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#182 Functional Outcome Assessment
Description:
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 within two days of the date of the identified deficiencies.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Description:
Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within 3.5 hours of time last known well and for whom IV thrombolytic therapy was initiated within 4.5 hours of time last known well.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
Description:
Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the performance period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#217 Functional Status Change for Patients with Knee Impairments
Description:
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with knee impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#218 Functional Status Change for Patients with Hip Impairments
Description:
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with hip impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#219 Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
Description:
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with foot, ankle or lower leg impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#220 Functional Status Change for Patients with Low Back Impairments
Description:
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with low back impairments. The change in FS is assessed using the FOTO Low Back FS 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#221 Functional Status Change for Patients with Shoulder Impairments
Description:
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in FS is assessed using the FOTO Shoulder FS 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#222 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
Description:
A patient-reported outcome measure (PROM) 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 FOTO Elbow/Wrist/Hand FS 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Description:
Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#236 Controlling High Blood Pressure
Description:
Percentage 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 period.-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#238 Use of High-Risk Medications in Older Adults
Description:
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
Description:
Percentage 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. 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 activity.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#240 Childhood Immunization Status
Description:
Percentage 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 or four 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 birthday.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting
Description:
Percentage 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 program.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#249 Barrett's Esophagus
Description:
Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#250 Radical Prostatectomy Pathology Reporting
Description:
Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
Description:
Percentage 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 location.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#259 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)
Description:
Percent 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).-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
Description:
Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) who are discharged to home no later than post-operative day #2.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer
Description:
The 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) procedure.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
Description:
Percentage 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 pregnancy.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
Description:
Percentage 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) therapy.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#277 Sleep Apnea: Severity Assessment at Initial Diagnosis
Description:
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
Description:
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available).-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#281 Dementia: Cognitive Assessment
Description:
Percentage 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 period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#282 Dementia: Functional Status Assessment
Description:
Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
Description:
Percentage 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 resources.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#288 Dementia: Education and Support of Caregivers for Patients with Dementia
Description:
Percentage 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 months.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#290 Assessment of Mood Disorders and Psychosis for Patients with Parkinson's Disease
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#291 Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease
Description:
Percentage of all patients with a diagnosis of Parkinson's disease (PD) who were assessed for cognitive impairment or dysfunction once during the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#293 Rehabilitative Therapy Referral for Patients with Parkinson's Disease
Description:
Percentage of all patients with a diagnosis of Parkinson's Disease (PD) who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#303 Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
Description:
Percentage 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 survey.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
Description:
Percentage 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 Survey.-
NQS Domain:
- -
Measure Type:
Patient Engagement/ Experience -
High Priority Measure:
Yes
#305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Description:
Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported): Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode. Percentage of patients who engaged in ongoing treatment, including two additional interventions or short-term medications, or one long-term medication for the treatment of SUD, within 34 days of the initiation.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#309 Cervical Cancer Screening
Description:
Percentage 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 within the last 3 years Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#310 Chlamydia Screening for Women
Description:
Percentage of women 16-24 years of age who were identified as sexually active at any time during the measurement period and who had at least one test for chlamydia during the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#318 Falls: Screening for Future Fall Risk
Description:
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Description:
Percentage of patients aged 45 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 report.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#321 CAHPS for MIPS Clinician/Group Survey
Description:
The 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 CBE endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows:- Getting timely care, appointments, and information (Not endorsed by CBE);
- How well providers Communicate (Not endorsed by CBE);
- Patient's Rating of Provider (CBE endorsed #0005);
- Access to Specialists (Not endorsed by CBE);
- Health Promotion & Education (Not endorsed by CBE);
- Shared Decision Making (Not endorsed by CBE);
- Health Status/Functional Status (Not endorsed by CBE);
- Courteous and Helpful Office Staff (CBE endorsed #0005);
- Care Coordination (Not endorsed by CBE); and
- Stewardship of Patient Resources (Not endorsed by CBE).
-
NQS Domain:
- -
Measure Type:
Patient Engagement/ Experience -
High Priority Measure:
Yes
#322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
Description:
Percentage 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 period.-
NQS Domain:
- -
Measure Type:
Efficiency -
High Priority Measure:
Yes
#326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Description:
Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
Description:
Percentage 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 symptoms.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Description:
Percentage 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 diagnosis.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#335 Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#336 Maternity Care: Postpartum Follow-Up and Care Coordination
Description:
Percentage 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: breastfeeding 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 update.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#338 HIV Viral Load Suppression
Description:
Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period, with an eligible encounter in the first 240 days of the performance period, whose last HIV viral load test result was less than 200 copies/mL during the performance period.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#340 HIV Medical Visit Frequency
Description:
Percentage 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 visits.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
Description:
Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#350 Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#351 Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
Description:
Percentage 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).-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#354 Anastomotic Leak Intervention
Description:
Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#355 Unplanned Reoperation within the 30 Day Postoperative Period
Description:
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30-day postoperative period.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#356 Unplanned Hospital Readmission within 30 Days of Principal Procedure
Description:
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#357 Surgical Site Infection (SSI)
Description:
Percentage of patients aged 18 years and older who had a surgical site infection (SSI).-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#358 Patient-Centered Surgical Risk Assessment and Communication
Description:
Percentage 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 surgeon.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Description:
Percentage 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 study.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
Description:
Percentage 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).-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#366 Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Description:
Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#370 Depression Remission at Twelve Months
Description:
The 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.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#374 Closing the Referral Loop: Receipt of Specialist Report
Description:
Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#376 Functional Status Assessment for Total Hip Replacement
Description:
Percentage of patients 19 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 300 - 425 days after the surgery.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#377 Functional Status Assessments for Heart Failure
Description:
Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#378 Children Who Have Dental Decay or Cavities
Description:
Percentage of children, 1 - 20 years of age at the start of the measurement period, who have had tooth decay or cavities during the measurement period as determined by a dentist.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#379 Primary Caries Prevention Intervention as Offered by Dentists
Description:
Percentage of children, 1 - 20 years of age, who received two fluoride varnish applications during the measurement period as determined by a dentist.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#382 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Description:
Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#383 Adherence to Antipsychotic Medications For Individuals with Schizophrenia
Description:
Percentage 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 period.-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
Description:
Patients 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 surgery.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
Description:
Patients 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 eye.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
Description:
Percentage 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, lawful physician-hastened death, or hospice) or whose existing end of life plan was reviewed or updated at least once annually or more frequently as clinically indicated (i.e., rapid progression).-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Description:
Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#389 Cataract Surgery: Difference Between Planned and Final Refraction
Description:
Percentage 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) refraction.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
Description:
Rate 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 older
-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#393 Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
Description:
Infection rate following CIED device implantation, replacement, or revision.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#394 Immunizations for Adolescents
Description:
The 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#395 Lung Cancer Reporting (Biopsy/Cytology Specimens)
Description:
Pathology 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#396 Lung Cancer Reporting (Resection Specimens)
Description:
Pathology 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#397 Melanoma Reporting
Description:
Pathology 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#398 Optimal Asthma Control
Description:
Composite 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 exacerbation.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#400 One-Time Screening for Hepatitis C Virus (HCV) for all Patients
Description:
Percentage of patients aged >= 18 years who have never been tested for Hepatitis C Virus (HCV) infection who receive an HCV infection test AND who have treatment initiated within three months or who are referred to a clinician who treats HCV infection within one month if tested positive for HCV.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Description:
Percentage 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 period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#404 Anesthesiology Smoking Abstinence
Description:
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions
Description:
Percentage 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
-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#406 Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
Description:
Percentage 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 recommended.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#409 Clinical Outcome Post Endovascular Stroke Treatment
Description:
Percentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#410 Psoriasis: Clinical Response to Systemic Medications
Description:
Percentage 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 treatment.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#413 Door to Puncture Time for Endovascular Stroke Treatment
Description:
Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Description:
Percentage 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 CT.-
NQS Domain:
- -
Measure Type:
Efficiency -
High Priority Measure:
Yes
#416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Description:
Percentage 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 injury.-
NQS Domain:
- -
Measure Type:
Efficiency -
High Priority Measure:
Yes
#418 Osteoporosis Management in Women Who Had a Fracture
Description:
The percentage of women 50-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#419 Overuse of Imaging for the Evaluation of Primary Headache
Description:
Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
Description:
Percentage 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 treatment.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#421 Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
Description:
Percentage 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 attempts.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
Description:
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#424 Perioperative Temperature Management
Description:
Percentage 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 15 minutes immediately after anesthesia end time.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#430 Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy
Description:
Percentage 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 anti-emetic agents of different classes preoperatively and/or intraoperatively.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Description:
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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Description:
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Description:
Percentage 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 surgery.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Description:
Percentage of final reports for patients aged 18 years and older undergoing computed tomography (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 technique.
-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Description:
Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the performance period: All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR Patients aged 20 to 75 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 to 75 years with a diagnosis of diabetes; OR Patients aged 40 to 75 with a 10-year ASCVD risk score of = 20 percent.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#439 Age Appropriate Screening Colonoscopy
Description:
The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.-
NQS Domain:
- -
Measure Type:
Efficiency -
High Priority Measure:
Yes
#440 Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician
Description:
Percentage 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 pathologist.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
Description:
The 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. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:- Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND
- Most recent tobacco status is Tobacco Free -- AND
- Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND
- Statin Use Unless Contraindicated
-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#443 Non-Recommended Cervical Cancer Screening in Adolescent Females
Description:
The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
Description:
Percent 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.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#448 Appropriate Workup Prior to Endometrial Ablation
Description:
Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#450 Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer
Description:
Percentage of female patients aged 18 to 70 with stage I (T1c) - III HER2 positive breast cancer for whom appropriate treatment is initiated.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#451 RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer Who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
Description:
Percentage 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 performed.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#452 Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
Description:
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#453 Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score - better)
Description:
Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#457 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)
Description:
Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#459 Back Pain After Lumbar Surgery
Description:
For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion 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 or a numeric pain scale at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#461 Leg Pain After Lumbar Surgery
Description:
For patients 18 years of age or older who had a lumbar discectomy/laminectomy or 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 or a numeric pain scale at three months (6 to 20 weeks) for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#462 Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
Description:
Percentage of patients 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#463 Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)
Description:
Percentage 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 intraoperatively.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#464 Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use
Description:
Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries
Description:
The 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 arteries.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#468 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
Description:
Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#470 Functional Status After Primary Total Knee Replacement
Description:
For 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) postoperatively.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#471 Functional Status After Lumbar Surgery
Description:
For patients age 18 and older who had lumbar discectomy/laminectomy or 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 three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure. * hereafter referred to as ODI-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#472 Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#475 HIV Screening
Description:
Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for Human immunodeficiency virus (HIV).-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#476 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
Description:
Percentage 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.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#477 Multimodal Pain Management
Description:
Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#478 Functional Status Change for Patients with Neck Impairments
Description:
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS 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, individual clinician, and clinic levels to assess quality.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups
Description:
This measure is a re-specified version of the measure, "Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition" (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group's readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#480 Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)
Description:
This measure is a re-specified version of the measure, "Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)" (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups ("provider") and assesses each provider's complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#481 Intravesical Bacillus-Calmette-Guerin for Non-muscle Invasive Bladder Cancer
Description:
Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#482 Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate
Description:
Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.-
NQS Domain:
- -
Measure Type:
Intermediate Outcome -
High Priority Measure:
Yes
#483 Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)
Description:
The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient's relationship with the clinician or practice.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#484 Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
Description:
Annual risk-standardized rate of acute, unplanned hospital admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs).-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#485 Psoriasis - Improvement in Patient-Reported Itch Severity
Description:
The percentage of patients, aged 8 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient- reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 3 or more points at a follow- up visit.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#486 Dermatitis - Improvement in Patient-Reported Itch Severity
Description:
The percentage of patients aged 8 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient-reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 3 or more points at a follow-up visit.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#487 Screening for Social Drivers of Health
Description:
Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#488 Kidney Health Evaluation
Description:
Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#489 Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy
Description:
Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within a 12-month period.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#490 Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors
Description:
Percentage of patients, aged 18 years and older, with a diagnosis of cancer, on immune checkpoint inhibitor therapy, and grade 2 or above diarrhea and/or grade 2 or above colitis, who have immune checkpoint inhibitor therapy held and corticosteroids or immunosuppressants prescribed or administered.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#491 Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma
Description:
Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#492 Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System
Description:
Annual risk-standardized rate of acute, unplanned cardiovascular-related admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with heart failure (HF) or cardiomyopathy.-
NQS Domain:
- -
Measure Type:
Outcome -
High Priority Measure:
Yes
#493 Adult Immunization Status
Description:
Percentage of patients 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.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#495 Ambulatory Palliative Care Patients' Experience of Feeling Heard and Understood
Description:
The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
#496 Cardiovascular Disease (CVD) Risk Assessment Measure -Proportion of Pregnant/Postpartum Patients that Receive VD Risk Assessment with a Standardized Instrument
Description:
Percentage of pregnant or postpartum patients who received a cardiovascular disease (CVD) risk assessment with a standardized instrument.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#497 Preventive Care and Wellness (composite)
Description:
Percentage of patients who received age- and sex-appropriate preventive screenings and wellness services. This measure is a composite of seven component measures that are based on recommendations for preventive care by the U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), American Association of Clinical Endocrinology (AACE), and American College of Endocrinology (ACE).-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#498 Connection to Community Service Provider
Description:
Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least one of their HRSNs within 60 days after screening.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#499 Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy
Description:
Percentage of patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) who, within seven (7) weeks following the date of injection, are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP = 25 mm Hg for injected eye OR if the IOP was >25 mm Hg, a plan of care was documented.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#500 Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up
Description:
Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 8 weeks.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#501 Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up
Description:
Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) and acute vitreous hemorrhage in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 2 weeks.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
No
#502 Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder
Description:
The percentage of patients aged 18 and older with a mental and/or substance use disorder who demonstrated improvement or maintenance of functioning based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) or Sheehan Disability Scale (SDS) 30 to 180 days after an index assessment.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-based Performance Measure -
High Priority Measure:
Yes
#503 Gains in Patient Activation Measure (PAM®) Scores at 12 Months
Description:
The Patient Activation Measure® (PAM®) is a 10- or 13-item questionnaire that assesses an individual's knowledge, skills, and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM® performance measure (PAM®-PM) is the change in score on the PAM® from baseline to follow-up measurement.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-based Performance Measure -
High Priority Measure:
Yes
#504 Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk
Description:
Percentage of adult aged 18 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.-
NQS Domain:
- -
Measure Type:
Process -
High Priority Measure:
Yes
#505 Reduction in Suicidal Ideation or Behavior Symptoms
Description:
The percentage of patients aged 18 years and older with a mental and/or substance use disorder AND suicidal thoughts, behaviors or risk symptoms who demonstrated a reduction in suicidal ideation and/or behavior symptoms based on results from the Columbia-Suicide Severity Rating Scale 'Screen Version' or 'Since Last Visit' (C-SSRS), within 120 days after an index assessment.-
NQS Domain:
- -
Measure Type:
Patient-Reported Outcome-Based Performance Measure -
High Priority Measure:
Yes
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