What Are Quality Measure Benchmarks?
When clinicians or groups submit measures for the Merit-based Incentive Payment System (MIPS) quality performance category, their performance on each measure is compared against the measure's benchmark to determine how many points the measure earns. Beginning in program year 2024, a clinician or group can receive anywhere from 1 to 10 points for each MIPS measure based on this comparison as long as the data completeness standards and case minimum requirements are met. Measures without an available historical or performance period benchmark will receive 0 points, even when data completeness and case minimum requirements are met (small practices will continue to receive 3 points).
Benchmarks are specific to the collection type: Qualified Clinical Data Registry (QCDR) measures, MIPS Clinical Quality Measures (MIPS CQMs)*, eCQMs, CMS Web Interface measures, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey, and Part B Claims measures. In order to measure performance that is comparable across the spectrum of performance, benchmarks are established using historical data. Historical benchmarks for the 2024 performance period for eCQMs, MIPS CQMs, QCDR measures, and Medicare Part B claims measures are based on actual performance data that were submitted for the 2021 performance period. *MIPS CQMs are measures submitted using registry rules.
How Do Benchmarks Work for Multi-Performance Rate Measures?
Several MIPS quality measures require the collection and submission of data for multiple populations. This means that there can be multiple performance rates associated with a single measure. Historical benchmarks for multi-performance rate measures are created based on an "overall performance rate" (based on a weighted average, simple average, or CMS-specified performance rate):
- #9 Anti-Depressant Medication Management - Simple Average
- #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - 2nd Performance Rate
- #238 Use of High-Risk Medications in Older Adults - 1st Performance Rate
- #239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents - Simple Average
- #305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment - Simple Average
- #366 Follow-Up Care for Children Prescribed ADHD Medication (ADD) - 2nd Performance Rate
- #370 Depression Remission at Twelve Months - Weighted Average
- #391 Follow-Up After Hospitalization for Mental Illness (FUH) - 2nd Performance Rate
- #392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation - 5th Performance Rate
- #394 Immunizations for Adolescents - 4th Performance Rate
- #398 Optimal Asthma Control - 1st Performance Rate
- #431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling - 2nd Performance Rate
- #493 Adult Immunization Status - Weighted Average
How Are Benchmarks Displayed?
Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see table below). The table identifies the range of points generally available for each measure, based on which decile a clinician or group's performance rate falls into. Clinicians who receive a score in the first decile will receive 1 point. Clinicians who are in the 3rd decile will receive somewhere between 3 and 3.9 points depending on their exact position in the decile, and clinicians in higher deciles will receive a corresponding number of points. For example, if a clinician submits performance data of 83% on a non-inverse measure, and the 5th decile begins at 72% and the 6th decile begins at 85%, then the clinician will receive between 5 and 5.9 points because 83% is in the 5th decile. For inverse measures where a higher performance is seen by a lower number on the performance score, the scores are reversed in the benchmark deciles (example: Measure 1). An Excel version of the 2024 MIPS Quality Historical Benchmarks can be found here.
*Measures marked in blue (example: Measure 130) can only earn a maximum score of 7 points. Topped-out means that the national median performance rate is so high that there is no meaningful difference in performance between clinicians.
Specialty Measure Set
Show Measures with 10 Point Potential
Quality Benchmarks displayed:
| M. Name | M. ID | Coll Type | Dec 1 | Dec 2 | Dec 3 | Dec 4 | Dec 5 | Dec 6 | Dec 7 | Dec 8 | Dec 9 | Dec 10 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 001 | MIPS CQM | 99.00 - 90.01 | 90.00 - 80.01 | 80.00 - 70.01 | 70.00 - 60.01 | 60.00 - 50.01 | 50.00 - 40.01 | 40.00 - 30.01 | 30.00 - 20.01 | 20.00 - 10.01 | <= 10.00 |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 001 | eCQM | 99.50 - 93.63 | 93.62 - 72.22 | 72.21 - 53.19 | 53.18 - 41.63 | 41.62 - 34.16 | 34.15 - 29.06 | 29.05 - 24.26 | 24.25 - 19.84 | 19.83 - 14.54 | <= 14.53 |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 001 | Medicare Part B Claims | 99.00 - 90.01 | 90.00 - 80.01 | 80.00 - 70.01 | 70.00 - 60.01 | 60.00 - 50.01 | 50.00 - 40.01 | 40.00 - 30.01 | 30.00 - 20.01 | 20.00 - 10.01 | <= 10.00 |
| 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) | 005 | MIPS CQM | 42.86 - 90.27 | 90.28 - 96.54 | 96.55 - 98.98 | 98.99 - 99.99 | -- | -- | 100 | -- | -- | -- |
| 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) | 005 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | 006 | MIPS CQM | 48.81 - 79.82 | 79.83 - 87.37 | 87.38 - 91.33 | 91.34 - 94.84 | 94.85 - 97.43 | 97.44 - 99.99 | -- | -- | -- | 100 |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 007 | MIPS CQM | 61.29 - 80.55 | 80.56 - 86.62 | 86.63 - 89.55 | 89.56 - 92.97 | 92.98 - 95.70 | 95.71 - 98.19 | 98.20 - 99.99 | -- | -- | 100 |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 007 | eCQM | 42.86 - 78.32 | 78.33 - 83.81 | 83.82 - 86.66 | 86.67 - 88.63 | 88.64 - 90.19 | 90.20 - 91.66 | 91.67 - 93.00 | 93.01 - 94.73 | 94.74 - 96.46 | >= 96.47 |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 008 | MIPS CQM | 43.33 - 94.28 | 94.29 - 97.93 | 97.94 - 99.41 | 99.42 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 008 | eCQM | 31.18 - 82.60 | 82.61 - 86.66 | 86.67 - 89.12 | 89.13 - 90.90 | 90.91 - 92.46 | 92.47 - 93.68 | 93.69 - 94.99 | 95.00 - 96.49 | 96.50 - 98.22 | >= 98.23 |
| Anti-Depressant Medication Management | 009 | eCQM | 10.40 - 66.97 | 66.98 - 74.31 | 74.32 - 77.02 | 77.03 - 79.25 | 79.26 - 81.24 | 81.25 - 82.89 | 82.90 - 84.37 | 84.38 - 86.76 | 86.77 - 90.62 | >= 90.63 |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 012 | eCQM | 4.43 - 70.52 | 70.53 - 85.70 | 85.71 - 90.80 | 90.81 - 93.99 | 94.00 - 96.25 | 96.26 - 97.66 | 97.67 - 98.69 | 98.70 - 99.43 | 99.44 - 99.99 | 100.00 |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 019 | MIPS CQM | 4.44 - 88.29 | 88.30 - 97.82 | 97.83 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 019 | eCQM | 9.52 - 50.42 | 50.43 - 69.49 | 69.50 - 77.94 | 77.95 - 83.59 | 83.60 - 88.35 | 88.36 - 91.35 | 91.36 - 93.97 | 93.98 - 96.54 | 96.55 - 98.75 | >= 98.76 |
| Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | 024 | MIPS CQM | 0.60 - 44.34 | 44.35 - 68.10 | 68.11 - 77.77 | 77.78 - 84.65 | 84.66 - 91.59 | 91.60 - 96.94 | 96.95 - 99.99 | -- | -- | 100.00 |
| Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | 024 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 039 | MIPS CQM | 0.25 - 6.70 | 6.71 - 21.96 | 21.97 - 42.30 | 42.31 - 54.65 | 54.66 - 63.25 | 63.26 - 71.19 | 71.20 - 81.19 | 81.20 - 89.65 | 89.66 - 97.97 | >= 97.98 |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 039 | Medicare Part B Claims | 1.52 - 24.99 | 25.00 - 52.24 | 52.25 - 65.57 | 65.58 - 73.77 | 73.78 - 82.34 | 82.35 - 88.55 | 88.56 - 96.18 | 96.19 - 99.22 | 99.23 - 99.99 | 100.00 |
| Advance Care Plan | 047 | MIPS CQM | 0.21 - 14.72 | 14.73 - 53.34 | 53.35 - 76.44 | 76.45 - 88.37 | 88.38 - 95.45 | 95.46 - 98.91 | 98.92 - 99.89 | 99.90 - 99.99 | -- | 100.00 |
| Advance Care Plan | 047 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 048 | MIPS CQM | 3.44 - 52.93 | 52.94 - 82.63 | 82.64 - 93.15 | 93.16 - 98.04 | 98.05 - 99.58 | 99.59 - 99.99 | 100.00 | -- | -- | -- |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 050 | MIPS CQM | 6.45 - 49.99 | 50.00 - 73.60 | 73.61 - 79.79 | 79.80 - 85.05 | 85.06 - 90.07 | 90.08 - 97.09 | 97.10 - 99.99 | -- | -- | 100 |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 052 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Treatment for Upper Respiratory Infection (URI) | 065 | MIPS CQM | 52.69 - 88.36/td> | 88.37 - 92.61 | 92.62 - 94.91 | 94.92 - 96.11 | 96.12 - 97.23 | 97.24 - 98.26 | 98.27 - 98.89 | 98.90 - 99.44 | 99.45 - 99.99 | 100.00 |
| Appropriate Treatment for Upper Respiratory Infection (URI) | 065 | eCQM | 26.42 - 72.31 | 72.32 - 84.34 | 84.35 - 88.93 | 88.94 - 91.73 | 91.74 - 94.28 | 94.29 - 96.31 | 96.32 - 97.95 | 97.96 - 99.31 | 99.32 - 99.99 | 100.00 |
| Appropriate Testing for Pharyngitis | 066 | MIPS CQM | 34.65 - 91.22 | 91.23 - 94.77 | 94.78 - 96.93 | 96.94 - 98.17 | 98.18 - 99.32 | 99.33 - 99.89 | 99.90 - 100.00 | -- | -- | -- |
| Appropriate Testing for Pharyngitis | 066 | eCQM | 1.05 - 9.99 | 10.00 - 29.16 | 29.17 - 46.13 | 46.14 - 60.60 | 60.61 - 69.37 | 69.38 - 77.41 | 77.42 - 83.42 | 83.43 - 87.84 | 87.85 - 91.13 | >= 91.14 |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | 104 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Breast Cancer Screening | 112 | MIPS CQM | 0.43 - 29.73 | 29.74 - 49.38 | 49.39 - 58.08 | 58.09 - 67.08 | 67.09 - 75.15 | 75.16 - 79.60 | 79.61 - 86.35 | 86.36 - 94.05 | 94.06 - 99.99 | 100.00 |
| Breast Cancer Screening | 112 | eCQM | 0.20 - 8.28 | 8.29 - 28.45 | 28.46 - 42.75 | 42.76 - 52.41 | 52.42 - 59.78 | 59.79 - 65.63 | 65.64 - 71.42 | 71.43 - 77.11 | 77.12 - 84.55 | >= 84.56 |
| Breast Cancer Screening | 112 | Medicare Part B Claims | 2.25 - 34.03 | 34.04 - 67.91 | 67.92 - 75.85 | 75.86 - 84.09 | 84.10 - 92.18 | 92.19 - 95.87 | 95.88 - 98.65 | 98.66 - 99.99 | -- | 100.00 |
| Colorectal Cancer Screening | 113 | MIPS CQM | 1.16 - 31.77 | 31.78 - 51.57 | 51.58 - 62.55 | 62.56 - 70.30 | 70.31 - 77.01 | 77.02 - 84.18 | 84.19 - 88.31 | 88.32 - 94.59 | 94.60 - 99.54 | >= 99.55 |
| Colorectal Cancer Screening | 113 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Colorectal Cancer Screening | 113 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | 116 | MIPS CQM | 36.11 - 76.31 | 76.32 - 86.04 | 86.05 - 89.24 | 89.25 - 92.69 | 92.70 - 94.25 | 94.26 - 95.88 | 95.89 - 97.63 | 97.64 - 98.60 | 98.61 - 99.99 | 100.00 |
| Diabetes: Eye Exam | 117 | MIPS CQM | 10.26 - 79.99 | 80.00 - 96.45 | 96.46 - 99.20 | 99.21 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Diabetes: Eye Exam | 117 | eCQM | 0.50 - 6.32 | 6.33 - 16.14 | 16.15 - 27.24 | 27.25 - 41.08 | 41.09 - 65.66 | 65.67 - 93.56 | 93.57 - 98.45 | 98.46 - 99.65 | 99.66 - 99.99 | 100.00 |
| Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 118 | MIPS CQM | 37.29 - 73.73 | 73.74 - 78.14 | 78.15 - 81.96 | 81.97 - 85.22 | 85.23 - 88.09 | 88.10 - 91.57 | 91.58 - 97.77 | 97.78 - 99.99 | -- | 100.00 |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | 126 | MIPS CQM | 0.81 - 27.91 | 27.92 - 66.36 | 66.37 - 88.76 | 88.77 - 98.30 | 98.31 - 99.99 | -- | 100.00 | -- | -- | -- |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | 127 | MIPS CQM | 0.95 - 54.06 | 54.07 - 87.69 | 87.70 - 97.91 | 97.92 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | MIPS CQM | 1.20 - 39.82 | 39.83 - 75.09 | 75.10 - 91.88 | 91.89 - 98.31 | 98.32 - 99.75 | 99.76 - 99.99 | 100.00 | -- | -- | -- |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | eCQM | 4.31 - 18.11 | 18.12 - 22.08 | 22.09 - 25.61 | 25.62 - 29.94 | 29.95 - 36.83 | 36.84 - 51.42 | 51.43 - 73.21 | 73.22 - 87.41 | 87.42 - 96.48 | >= 96.49 |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Medicare Part B Claims | 14.94 - 67.50 | 67.51 - 94.85 | 94.86 - 99.08 | 99.09 - 99.87 | 99.88 - 99.99 | -- | 100.00 | -- | -- | -- |
| Documentation of Current Medications in the Medical Record | 130 | MIPS CQM | 3.80 - 68.12 | 68.13 - 92.99 | 93.00 - 98.22 | 98.23 - 99.64 | 99.65 - 99.94 | 99.95 - 99.99 | 100.00 | -- | -- | -- |
| Documentation of Current Medications in the Medical Record | 130 | eCQM | 5.12 - 61.37 | 61.38 - 80.24 | 80.25 - 87.90 | 87.91 - 92.23 | 92.24 - 95.20 | 95.21 - 97.07 | 97.08 - >= 99.88 | -- | -- | -- |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | MIPS CQM | 0.05 - 61.76 | 61.77 - 89.45 | 89.46 - 97.24 | 97.25 - 99.21 | 99.22 - 99.96 | 99.97 - 99.99 | 100:00 | -- | -- | -- |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | Medicare Part B Claims | 2.38 - 90.27 | 90.28 - 99.43 | 99.44 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Melanoma: Continuity of Care – Recall System | 137 | MIPS CQM | 9.58 - 95.54 | 95.55 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | MIPS CQM | 10.13 - 86.05 | 86.06 - 94.42 | 94.43 - 97.38 | 97.39 - 98.94 | 98.95 - 99.53 | 99.54 - 99.86 | 99.87 - 99.99 | -- | -- | 100.00 |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Oncology: Oncology: Medical and Radiation – Pain Intensity Quantified | 143 | MIPS CQM | 1.60 - 81.72 | 81.73 - 97.05 | 97.06 - 99.53 | 99.54 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | eCQM | 2.12 - 24.04 | 24.05 - 77.94 | 77.95 - 90.64 | 90.65 - 94.62 | 94.63 - 96.71 | 96.72 - 98.05 | 98.06 - 100.00 | -- | -- | -- |
| Oncology: Medical and Radiation – Plan of Care for Pain | 144 | MIPS CQM | 7.89 - 56.67 | 56.68 - 83.77 | 83.78 - 90.51 | 90.52 - 94.58 | 94.59 - 97.08 | 97.09 - 98.90 | 98.91 - 99.79 | 99.80 - 99.99 | -- | 100.00 |
| Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | 145 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | 145 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Falls: Plan of Care | 155 | MIPS CQM | 18.29 - 93.05 | 93.06 - 99.81 | 99.82 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Falls: Plan of Care | 155 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Tuberculosis Screening Prior to First Course Biologic Therapy | 176 | MIPS CQM | 18.63 - 67.38 | 67.39 - 81.81 | 81.82 - 91.22 | 91.23 - 98.35 | 98.36 - 99.99 | -- | 100.00 | -- | -- | -- |
| Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | MIPS CQM | 6.62 - 64.80 | 64.81 - 77.93 | 77.94 - 86.70 | 86.71 - 92.08 | 92.09 - 97.89 | 97.90 - 99.61 | 99.62 - 100.00 | -- | -- | -- |
| Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | MIPS CQM | 5.00 - 75.12 | 75.13 - 91.14 | 91.15 - 94.85 | 94.86 - 98.40 | 98.41 - 99.76 | 99.77 - 99.99 | 100.00 | -- | -- | -- |
| Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | MIPS CQM | 54.05 - 68.69 | 68.70 - 78.07 | 78.08 - 87.87 | 87.88 - 95.75 | 95.76 - 99.32 | 99.33 - 99.74 | 99.75 - 100.00 | -- | -- | -- |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | MIPS CQM | 55.00 - 98.48 | 98.49 - 99.84 | 99.85 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Medicare Part B Claims | 0.44 - 96.74 | 96.75 - 99.99 | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Functional Outcome Assessment | 182 | MIPS CQM | 0.10 - 98.90 | 98.91 - 99.84 | 99.85 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | 185 | MIPS CQM | 12.91 - 86.49 | 86.50 - 96.80 | 96.81 - 99.51 | 99.52 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | MIPS CQM | 42.86 - 90.55 | 90.56 - 94.41 | 94.42 - 97.91 | 97.92 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | MIPS CQM | 51.85 - 93.74 | 93.75 - 97.04 | 97.05 - 98.53 | 98.54 - 99.27 | 99.28 - 99.99 | -- | -- | -- | -- | 100.00 |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | eCQM | 28.70 - 82.28 | 82.29 - 91.06 | 91.07 - 94.66 | 94.67 - 96.42 | 96.43 - 97.49 | 97.50 - 98.30 | 98.31 - 98.92 | 98.93 - 99.51 | 99.52 - 99.99 | 100.00 |
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Knee Impairments | 217 | MIPS CQM | 29.27 - 42.41 | 42.42 - 52.37 | 52.38 - 56.93 | 56.94 - 63.37 | 63.38 - 72.93 | 72.94 - 79.99 | 80.00 - 90.23 | 90.24 - 99.99 | -- | 100.00 |
| Functional Status Change for Patients with Hip Impairments | 218 | MIPS CQM | 26.98 - 37.77 | 37.78 - 47.61 | 47.62 - 54.16 | 54.17 - 61.89 | 61.90 - 68.28 | 68.29 - 73.71 | 73.72 - 84.79 | 84.80 - 99.99 | -- | 100.00 |
| Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | 219 | MIPS CQM | 25.00 - 38.23 | 38.24 - 48.71 | 48.72 - 53.74 | 53.75 - 63.63 | 63.64 - 69.61 | 69.62 - 74.43 | 74.44 - 83.75 | 83.76 - 97.43 | 97.44 - 99.99 | 100.00 |
| Functional Status Change for Patients with Low Back Impairments | 220 | MIPS CQM | 29.71 - 45.97 | 45.98 - 53.01 | 53.02 - 58.17 | 58.18 - 67.96 | 67.97 - 75.29 | 75.30 - 81.35 | 81.36 - 93.54 | 93.55 - 99.99 | -- | 100.00 |
| Functional Status Change for Patients with Shoulder Impairments | 221 | MIPS CQM | 27.59 - 42.21 | 42.22 - 48.97 | 48.98 - 58.17 | 58.18 - 62.75 | 62.76 - 71.10 | 71.11 - 76.24 | 76.25 - 92.58 | 92.59 - 99.99 | -- | 100.00 |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | MIPS CQM | 23.81 - 49.99 | 50.00 - 57.13 | 57.14 - 61.53 | 61.54 - 67.85 | 67.86 - 74.92 | 74.93 - 78.70 | 78.71 - 82.75 | 82.76 - 94.43 | 94.44 - 99.99 | 100.00 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | MIPS CQM | 3.39 - 18.91 | 18.92 - 39.12 | 39.13 - 61.53 | 61.54 - 78.59 | 78.60 - 89.28 | 89.29 - 97.09 | 97.10 - 99.99 | -- | -- | 100.00 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | eCQM | 2.22 - 14.28 | 14.29 - 24.99 | 25.00 - 36.58 | 36.59 - 49.77 | 49.78 - 61.53 | 61.54 - 74.41 | 74.42 - 85.70 | 85.71 - 94.02 | 94.03 - 99.99 | 100.00 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Medicare Part B Claims | 14.29 - 78.16 | 78.17 - 95.93 | 95.94 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Controlling High Blood Pressure | 236 | MIPS CQM | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 |
| Controlling High Blood Pressure | 236 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Controlling High Blood Pressure | 236 | Medicare Part B Claims | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 |
| Use of High-Risk Medications in Older Adults | 238 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Use of High-Risk Medications in Older Adults | 238 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | 239 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Childhood Immunization Status | 240 | eCQM | 1.00 - 4.75 | 4.76 - 7.83 | 7.84 - 12.15 | 12.16 - 16.66 | 16.67 - 22.60 | 22.61 - 28.16 | 28.17 - 35.47 | 35.48 - 42.17 | 42.18 - 49.99 | >= 50.00 |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | MIPS CQM | 1.99 - 24.43 | 24.44 - 26.46 | 26.47 - 29.29 | 29.30 - 33.95 | 33.96 - 39.34 | 39.35 - 52.49 | 52.50 - 64.65 | 64.66 - 86.35 | 86.36 - 96.96 | >= 96.97 |
| Barrett’s Esophagus | 249 | MIPS CQM | 97.02 - 99.99 | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Barrett's Esophagus | 249 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Radical Prostatectomy Pathology Reporting | 250 | MIPS CQM | 97.86 - 99.99 | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Radical Prostatectomy Pathology Reporting | 250 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | MIPS CQM | 15.79 - 88.31 | 88.32 - 93.31 | 93.32 - 95.70 | 95.71 - 97.72 | 97.73 - 98.23 | 98.24 - 98.90 | 98.91 - 100.00 | -- | -- | -- |
| 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) | 259 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | MIPS CQM | 7.27 - 42.06 | 42.07 - 69.22 | 69.23 - 95.82 | 95.83 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Sleep Apnea: Severity Assessment at Initial Diagnosis | 277 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | 279 | MIPS CQM | 8.00 - 78.50 | 78.51 - 91.35 | 91.36 - 99.79 | 99.80 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Dementia: Cognitive Assessment | 281 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Dementia: Functional Status Assessment | 282 | MIPS CQM | 38.71 - 94.73 | 94.74 - 99.99 | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | 286 | MIPS CQM | 50.00 - 99.55 | 99.56 - 99.99 | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Dementia: Education and Support of Caregivers for Patients with Dementia | 288 | MIPS CQM | 0.82 - 78.32 | 78.33 - 94.33 | 94.34 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Assessment of Mood Disorders and Psychosis for Patients with Parkinson’s Disease | 290 | MIPS CQM | 13.79 - 70.36 | 70.37 - 90.70 | 90.71 - 97.49 | 97.50 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease | 291 | MIPS CQM | 7.55 - 40.23 | 40.24 - 82.59 | 82.60 - 96.66 | 96.67 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Rehabilitative Therapy Referral for Patients with Parkinson’s Disease | 293 | MIPS CQM | 4.43 - 56.81 | 56.82 - 92.91 | 92.92 - 97.61 | 97.62 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | 303 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | eCQM | 0.31 - 1.31 | 1.32 - 2.03 | 2.04 - 2.49 | 2.50 - 3.08 | 3.09 - 3.57 | 3.58 - 4.36 | 4.37 - 5.31 | 5.32 - 6.69 | 6.70 - 9.99 | >= 10.00 |
| Cervical Cancer Screening | 309 | eCQM | 0.34 - 7.88 | 7.89 - 16.34 | 16.35 - 23.77 | 23.78 - 30.94 | 30.95 - 37.23 | 37.24 - 43.85 | 43.86 - 50.30 | 50.31 - 57.82 | 57.83 - 68.89 | >= 68.90 |
| Chlamydia Screening for Women | 310 | eCQM | 0.84 - 7.68 | 7.69 - 12.49 | 12.50 - 18.74 | 18.75 - 24.99 | 25.00 - 30.70 | 30.71 - 36.89 | 36.90 - 43.47 | 43.48 - 49.99 | 50.00 - 60.23 | >= 60.24 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | MIPS CQM | 0.11 - 7.06 | 7.07 - 18.20 | 18.21 - 27.75 | 27.76 - 48.04 | 48.05 - 81.63 | 81.64 - 93.85 | 93.86 - 98.92 | 98.93 - 99.92 | 99.93 - 99.99 | 100.00 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | eCQM | 0.06 - 4.41 | 4.42 - 12.46 | 12.47 - 17.05 | 17.06 - 19.94 | 19.95 - 22.79 | 22.80 - 25.69 | 25.70 - 28.78 | 28.79 - 33.10 | 33.11 - 40.79 | >= 40.80 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Medicare Part B Claims | 0.17 - 23.20 | 23.21 - 79.04 | 79.05 - 95.66 | 95.67 - 99.08 | 99.09 - 99.77 | 99.78 - 99.99 | 100.00 | -- | -- | -- |
| Falls: Screening for Future Fall Risk | 318 | eCQM | 0.14 - 5.14 | 5.15 - 22.69 | 22.70 - 42.14 | 42.15 - 58.32 | 58.33 - 73.07 | 73.08 - 84.17 | 84.18 - 91.82 | 91.83 - 97.02 | 97.03 - 99.29 | >= 99.30 |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | MIPS CQM | 13.45 - 87.92 | 87.93 - 91.66 | 91.67 - 95.59 | 95.60 - 97.23 | 97.24 - 98.32 | 98.33 - 99.99 | 100.00 | -- | -- | -- |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | 322 | MIPS CQM | 99.77 - 0.01 | -- | -- | -- | -- | -- | -- | -- | -- | 0.00 |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy (Suppressed) | 326 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | MIPS CQM | 94.23 - 72.74 | 72.73 - 53.58 | 53.57 - 32.44 | 32.43 - 17.25 | 17.24 - 8.28 | 8.27 - 2.57 | 2.56 - 0.01 | -- | -- | 0.00 |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | MIPS CQM | 12.50 - 64.43 | 64.44 - 81.07 | 81.08 - 88.34 | 88.35 - 92.58 | 92.59 - 95.44 | 95.45 - 97.55 | 97.56 - 99.99 | -- | -- | 100.00 |
| Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) | 335 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Maternity Care: Postpartum Follow-Up and Care Coordination | 336 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Viral Load Suppression | 338 | MIPS CQM | 11.81 - 68.26 | 68.27 - 86.77 | 86.78 - 91.37 | 91.38 - 94.23 | 94.24 - 95.84 | 95.85 - 99.99 | -- | -- | -- | 100.00 |
| HIV Viral Load Suppression | 338 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Medical Visit Frequency | 340 | MIPS CQM | 32.07 - 58.64 | 58.65 - 72.65 | 72.66 - 79.77 | 79.78 - 85.05 | 85.06 - 86.35 | 86.36 - 89.18 | 89.19 - 92.91 | 92.92 - 99.99 | -- | 100.00 |
| Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | 344 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | 350 | MIPS CQM | 26.18 - 98.41 | 98.42 - 99.90 | 99.91 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | 351 | MIPS CQM | 47.98 - 91.95 | 91.96 - 99.03 | 99.04 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Anastomotic Leak Intervention | 354 | MIPS CQM | 23.33 - 6.38 | 6.37 - 4.00 | 3.99 - 2.63 | 2.62 - 1.29 | 1.28 - 0.18 | 0.17 - 0.01 | -- | -- | -- | 0.00 |
| Unplanned Reoperation within the 30 Day Postoperative Period | 355 | MIPS CQM | 35.82 - 1.81 | 1.80 - 0.82 | 0.81 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | 356 | MIPS CQM | 45.37 - 5.23 | 5.22 - 3.03 | 3.02 - 1.19 | 1.18 - 0.01 | -- | -- | -- | -- | -- | 0.00 |
| Surgical Site Infection (SSI) | 357 | MIPS CQM | 12.31 - 1.50 | 1.49 - 0.24 | 0.23 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 |
| Patient-Centered Surgical Risk Assessment and Communication | 358 | MIPS CQM | 0.62 - 20.95 | 20.96 - 90.59 | 90.60 - 98.90 | 98.91 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | 360 | MIPS CQM | 0.07 - 73.25 | 73.26 - 82.59 | 82.60 - 99.57 | 99.58 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 364 | MIPS CQM | 1.75 - 36.35 | 36.36 - 63.31 | 63.32 - 98.06 | 98.07 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Follow-Up Care for Children Prescribed ADHD Medication (ADD) | 366 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Depression Remission at Twelve Months | 370 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Depression Remission at Twelve Months | 370 | eCQM | 0.48 - 2.07 | 2.08 - 3.49 | 3.50 - 4.95 | 4.96 - 6.92 | 6.93 - 8.94 | 8.95 - 10.88 | 10.89 - 13.99 | 14.00 - 18.15 | 18.16 - 24.99 | >= 25.00 |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | eCQM | 0.73 - 8.32 | 8.33 - 18.60 | 18.61 - 27.37 | 27.38 - 35.16 | 35.17 - 43.01 | 43.02 - 51.29 | 51.30 - 60.18 | 60.19 - 72.08 | 72.09 - 89.28 | >= 89.29 |
| Functional Status Assessment for Total Hip Replacement | 376 | eCQM | 0.51 - 1.29 | 1.30 - 2.44 | 2.45 - 7.06 | 7.07 - 9.91 | 9.92 - 11.67 | 11.68 - 14.11 | 14.12 - 18.37 | 18.38 - 25.36 | 25.37 - 43.08 | >= 43.09 |
| Functional Status Assessments for Heart Failure | 377 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Children Who Have Dental Decay or Cavities | 378 | eCQM | 79.07 - 66.07 | 66.06 - 48.64 | 48.63 - 45.10 | 45.09 - 34.34 | 34.33 - 29.02 | 29.01 - 9.20 | 9.19 - 3.65 | 3.64 - 0.91 | 0.90 - 0.01 | 0.00 |
| Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 379 | eCQM | 0.01 - 0.04 | 0.05 - 0.23 | 0.24 - 0.48 | 0.49 - 0.99 | 1.00 - 1.72 | 1.73 - 3.11 | 3.12 - 4.57 | 4.58 - 6.93 | 6.94 - 11.02 | >= 11.03 |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | eCQM | 0.46 - 2.26 | 2.27 - 5.80 | 5.81 - 13.52 | 13.53 - 20.61 | 20.62 - 34.87 | 34.88 - 46.93 | 46.94 - 59.67 | 59.68 - 67.94 | 67.95 - 88.08 | >= 88.09 |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | MIPS CQM | 6.25 - 93.74 | 93.75 - 94.33 | 94.34 - 99.33 | 99.34 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | MIPS CQM | 67.57 - 79.16 | 79.17 - 83.99 | 84.00 - 90.47 | 90.48 - 95.82 | 95.83 - 97.61 | 97.62 - 99.34 | 99.35 - 100.00 | -- | -- | -- |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | MIPS CQM | 10.87 - 22.30 | 22.31 - 34.54 | 34.55 - 53.26 | 53.27 - 56.62 | 56.63 - 58.94 | 58.95 - 62.67 | 62.68 - 65.19 | 65.20 - 70.20 | 70.21 - 74.99 | >= 75.00 |
| Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | 386 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | 387 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cataract Surgery: Difference Between Planned and Final Refraction | 389 | MIPS CQM | 0.32 - 18.31 | 18.32 - 41.03 | 41.04 - 51.24 | 51.25 - 66.79 | 66.80 - 89.49 | 89.50 - 96.33 | 96.34 - 99.00 | 99.01 - 99.99 | -- | 100.00 |
| Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | 392 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | 393 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Immunizations for Adolescents | 394 | MIPS CQM | 1.06 - 10.95 | 10.96 - 15.78 | 15.79 - 19.99 | 20.00 - 23.07 | 23.08 - 26.66 | 26.67 - 30.55 | 30.56 - 33.54 | 33.55 - 39.99 | 40.00 - 53.84 | >= 53.85 |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | MIPS CQM | 87.50 - 99.99 | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Medicare Part B Claims | 88.37 - 99.99 | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Lung Cancer Reporting (Resection Specimens) | 396 | MIPS CQM | -- | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Lung Cancer Reporting (Resection Specimens) | 396 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Melanoma Reporting | 397 | MIPS CQM | 36.71 - 97.81 | 97.82 - 99.99 | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Melanoma Reporting | 397 | Medicare Part B Claims | 92.94 - 99.99 | -- | -- | -- | -- | -- | 100.00 | -- | -- | -- |
| Optimal Asthma Control | 398 | MIPS CQM | 0.15 - 3.33 | 3.34 - 4.37 | 4.38 - 29.90 | 29.91 - 56.12 | 56.13 - 76.00 | 76.01 - 95.01 | 95.02 - 98.81 | 98.82 - 99.99 | -- | 100.00 |
| One-Time Screening for Hepatitis C Virus (HCV) for all Patients | 400 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Anesthesiology Smoking Abstinence | 404 | MIPS CQM | 7.70 - 41.37 | 41.38 - 59.24 | 59.25 - 66.66 | 66.67 - 73.17 | 73.18 - 77.26 | 77.27 - 80.15 | 80.16 - 85.47 | 85.48 - 91.26 | 91.27 - 96.44 | >= 96.45 |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | MIPS CQM | 0.96 - 8.71 | 8.72 - 31.96 | 31.97 - 98.37 | 98.38 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Medicare Part B Claims | 0.47 - 4.07 | 4.08 - 6.66 | 6.67 - 16.91 | 16.92 - 26.91 | 26.92 - 57.13 | 57.14 - 76.70 | 76.71 - 97.00 | 97.01 - 99.99 | -- | 100.00 |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | MIPS CQM | 60.00 - 12.51 | 12.50 - 2.28 | 2.27 - 0.01 | -- | -- | -- | 0.00 | -- | -- | -- |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Medicare Part B Claims | 40.00 - 14.30 | 14.29 - 3.71 | 3.70 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 |
| Clinical Outcome Post Endovascular Stroke Treatment | 409 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Psoriasis: Clinical Response to Systemic Medications | 410 | MIPS CQM | 11.11 - 55.05 | 55.06 - 79.02 | 79.03 - 91.52 | 91.53 - 97.55 | 97.56 - 99.99 | -- | -- | -- | -- | 100.00 |
| Door to Puncture Time for Endovascular Stroke Treatment | 413 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | MIPS CQM | 80.56 - 93.74 | 93.75 - 96.10 | 96.11 - 96.90 | 96.91 - 98.11 | 98.12 - 99.36 | 99.37 - 99.99 | 100.00 | -- | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | MIPS CQM | 37.50 - 18.04 | 18.03 - 9.53 | 9.52 - 7.70 | 7.69 - 4.18 | 4.17 - 2.81 | 2.80 - 0.01 | -- | -- | -- | 0.00 |
| Osteoporosis Management in Women Who Had a Fracture | 418 | MIPS CQM | 1.04 - 5.44 | 5.45 - 9.08 | 9.09 - 12.02 | 12.03 - 14.94 | 14.95 - 15.99 | 16.00 - 18.17 | 18.18 - 22.63 | 22.64 - 32.13 | 32.14 - 58.32 | >= 58.33 |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Overuse of Imaging for the Evaluation of Primary Headache | 419 | MIPS CQM | 26.47 - 2.94 | 2.93 - 0.77 | 0.76 - 0.01 | -- | -- | -- | 0.00 | -- | -- | -- |
| Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | 420 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | 421 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Perioperative Temperature Management | 424 | MIPS CQM | 84.46 - 98.40 | 98.41 - 99.45 | 99.46 - 99.88 | 99.89 - 99.96 | 99.97 - 99.98 | 99.99 - 99.99 | 100.00 | -- | -- | -- |
| Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy | 430 | MIPS CQM | 83.13 - 96.12 | 96.13 - 99.14 | 99.15 - 99.73 | 99.74 - 99.88 | 99.89 - 99.95 | 99.96 - 99.99 | 100.00 | -- | -- | -- |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | 432 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 433 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | MIPS CQM | 38.16 - 96.39 | 96.40 - 99.90 | 99.91 - 99.99 | -- | -- | -- | 100.00 | -- | -- | -- |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Medicare Part B Claims | 0.46 - 82.96 | 82.97 - 96.51 | 96.52 - 98.89 | 98.90 - 99.58 | 99.59 - 99.99 | -- | 100.00 | -- | -- | -- |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Age Appropriate Screening Colonoscopy | 439 | MIPS CQM | 3.03 - 0.10 | 0.09 - 0.01 | -- | -- | -- | -- | -- | -- | -- | 0.00 |
| Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician | 440 | MIPS CQM | 70.53 - 97.15 | 97.16 - 98.56 | 98.57 - 99.43 | 99.44 - 99.94 | 99.95 - 99.99 | -- | 100.00 | -- | -- | -- |
| Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | 441 | MIPS CQM | 2.79 - 18.33 | 18.34 - 29.58 | 29.59 - 34.61 | 34.62 - 39.95 | 39.96 - 43.11 | 43.12 - 47.40 | 47.41 - 52.84 | 52.85 - 58.57 | 58.58 - 69.44 | >= 69.45 |
| Non-Recommended Cervical Cancer Screening in Adolescent Females | 443 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | 445 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Workup Prior to Endometrial Ablation | 448 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer | 450 | MIPS CQM | 43.33 - 68.41 | 68.42 - 74.99 | 75.00 - 80.86 | 80.87 - 84.37 | 84.38 - 86.81 | 86.82 - 89.99 | 90.00 - 92.58 | 92.59 - 94.11 | 94.12 - 99.99 | 100.00 |
| 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 | 451 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | 452 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better) | 453 | MIPS CQM | 31.82 - 20.84 | 20.83 - 16.01 | 16.00 - 13.54 | 13.53 - 11.28 | 11.27 - 9.37 | 9.36 - 7.96 | 7.95 - 6.26 | 6.25 - 4.56 | 4.55 - 2.97 | <= 2.96 |
| Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) | 457 | MIPS CQM | 77.78 - 22.59 | 22.58 - 19.49 | 19.48 - 13.66 | 13.65 - 11.75 | 11.74 - 8.91 | 8.90 - 5.68 | 5.67 - 3.57 | 3.56 - 1.97 | 1.96 - 0.01 | 0.00 |
| Back Pain After Lumbar Discectomy/Laminectomy | 459 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Leg Pain After Lumbar Discectomy/Laminectomy | 461 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | 462 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) | 463 | MIPS CQM | 58.11 - 97.72 | 97.73 - 99.60 | 99.61 - 99.86 | 99.87 - 99.99 | -- | -- | 100.00 | -- | -- | -- |
| Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | 464 | MIPS CQM | 30.77 - 77.60 | 77.61 - 85.22 | 85.23 - 90.69 | 90.70 - 92.85 | 92.86 - 94.77 | 94.78 - 96.29 | 96.30 - 97.45 | 97.46 - 99.99 | -- | 100.00 |
| Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | 465 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | 468 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status After Primary Total Knee Replacement | 470 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status After Lumbar Discectomy/Laminectomy | 471 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | 472 | eCQM | 11.48 - 4.09 | 4.08 - 1.97 | 1.96 - 0.01 | -- | -- | -- | 0.00 | -- | -- | -- |
| HIV Screening | 475 | eCQM | 0.13 - 4.58 | 4.59 - 8.63 | 8.64 - 12.31 | 12.32 - 15.32 | 15.33 - 18.25 | 18.26 - 21.86 | 21.87 - 26.17 | 26.18 - 32.08 | 32.09 - 41.80 | >= 41.81 |
| Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia | 476 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Multimodal Pain Management | 477 | MIPS CQM | 43.18 - 85.18 | 85.19 - 93.86 | 93.87 - 96.68 | 96.69 - 98.24 | 98.25 - 99.24 | 99.25 - 99.77 | 99.78 - 100.00 | -- | -- | -- |
| Functional Status Change for Patients with Neck Impairments | 478 | MIPS CQM | 22.58 - 34.86 | 34.87 - 48.80 | 48.81 - 56.00 | 56.01 - 58.26 | 58.27 - 62.75 | 62.76 - 69.21 | 69.22 - 73.86 | 73.87 - 87.84 | 87.85 - 99.99 | 100.00 |
| Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer | 481 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate | 482 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) | 483 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Psoriasis- Improvement in Patient-Reported Itch Severity | 485 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Dermatitis – Improvement in Patient-Reported Itch Severity | 486 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Screening for Social Drivers of Health | 487 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Kidney Health Evaluation | 488 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Kidney Health Evaluation | 488 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy | 489 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors | 490 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma | 491 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Immunization Status | 493 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood | 495 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument | 496 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Preventive Care and Wellness (composite) | 497 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Connection to Community Service Provider | 498 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate screening and plan of care for elevated intraocular pressure following intravitreal or periocular steroid therapy | 499 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Acute posterior vitreous detachment appropriate examination and follow-up | 500 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow-up | 501 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder | 502 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Gains in Patient Activation Measure (PAM) Scores at 12 Months | 503 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk | 504 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Reduction in Suicidal Ideation or Behavior Symptoms | 505 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |