2018 CMS MIPS Quality Measures

All 2018 CMS MIPS registry and EHR quality measures can be reported with MDinteractive.  Each provider will need to submit data on at >= 60% of applicable Medicare and non-Medicare patients on at least 6 quality measures for the entire year. Please check 2018 Measure Specifications for Claims and Registry Release Notes to see changes to existing measures made since the release of the 2017 MIPS Measure Specifications. Please use the Code Master file, if you are looking for the individual MIPS measures that apply to the specific ICD10 and/or CPT codes that you use to bill Medicare. You also can get additional information about the quality measures: 

How to choose MIPS quality measures

  • The following factors could be considered when deciding which measures to select for MIPS reporting:
    • Clinical conditions usually treated;
    • Types of care typically provided (e.g., preventive, chronic, acute);
    • Settings where care is usually delivered (e.g., office, emergency department [ED], surgical suite);
    • Quality improvement goals;
    • Other quality reporting programs in use or being considered;
       
  • Find out if any of the MIPS quality specialty sets apply to your specialty. You can find our suggestions by specialty here.
  • Because you will need to report at least 60% of the patients/visits eligible for a measure (ALL insurances, Medicare and not Medicare) you could select measures with a more defined demographic in order to create a manageable size report. 
  • There are several advantages of reporting MIPS at the group level instead of individual level:
    • Let's imagine a practice with one anesthesiologist, one pathologist, one hospitalist, one internist, one dermatologist and one cardiologist. If the providers report MIPS at the individual level, one potentially would need to manage and optimize the performance of  36 different quality measures. At the group level, one could report just the 6 best measures. The combination could be 2 anesthesia measures, 2 pathology measures and 2 hospitalist measures. There is no need to cover all specialties. One just needs to report the patients/visits eligible for the chosen measures. For example, measure #137 (Melanoma: Continuity of Care – Recall System) will only apply for patients seen by the dermatologist. Please note that there are measures that apply to patients seen by different specialties: for example measure #226  (Tobacco Use: Screening and Cessation Intervention) will apply to all outpatient office visits done by the internists, dermatologists and cardiologists. 
    • The same group level reporting advantages would apply with other MIPS components like Improvement Activities. For example, all 6 members of the practice described above could share on the MIPS points when just one  cardiologist is participating in the systematic anticoagulation program (high weighted Improvement Activity).
    • ACI: Satisfy the mandatory base score measures as a group. Base score measures are mandatory for ACI. If you participate in MIPS as an individual, your ACI score will be 0% unless you successfully meet the requirements of all the base score measures. But when you participate as part of a group, if another provider in your group fulfills a base score measure, then everybody in the group is considered to have fulfilled that measure.
  • It can be easier to report more specific measures that apply to smaller patient populations. For example, dermatologists could report melanoma measures #137, #138 and #224. However, one needs to report a minimum of 20 patients in order to get a score higher than 3.
  • Please note the reporting frequency of measures like measure #226 (Tobacco Use: Screening and Cessation Intervention) that only need to be reported once per patient per year versus measures like measure #130 (Documentation of Current Medications in the Medical Record) that need to be reported on each eligible visit. For example, measure #226 only needs to be reported once on a patient seen for a total of 7 times by 4 different providers at the group level. Measure #130 will need to be reported 7 times on this case.
  • Be aware of "easy" measures with which most providers already have high compliance (i.e. high national benchmarks). Medicare calls these measures "topped-out" measures. For example, measure #130 (Documentation of Current Medication in the Medical Record) has the following MIPS scoring:
    • 3 Points 61.27 - 82.11 %
    • 4 Points 82.12 - 91.71 %   - This means that a provider with a performance rate of 90% will only get 4 MIPS points
    • 5 Points 91.72 - 96.86 %   
    • 6 Points 96.87 - 99.30 %
    • 7 Points 99.31 - 99.99 %
    • 10 Points 100 % - This means that if a provider only gets 10 points on this measure if ALL patients had medications documented on ALL visits. If the documentation is not done once during the reporting period, the provider will get 7 points or less instead of 10.
  • Be aware of choosing measures without benchmarks. Measures without benchmarks can only earn maximum 3 points (unless the measure is a high priority or outcome measure where one could could get one or two additional bonus points).
  • You can find the MIPS quality measures benchmarks and which measures have no benchmarks or are topped-out on this CMS Excel file.
  • Example of MIPS quality measures which give 10 points with performances below 100%:
    • #400 Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk >= 20.02%
    • #343 Screening Colonoscopy Adenoma Detection Rate >= 80.33%
    • #39 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older >= 82.54%
    • #112 Breast Cancer Screening  >= 87.93%
    • #113 Colorectal Cancer Screening >= 88.15%
    • #111 Pneumonia Vaccination Status for Older Adults >= 90.20%
    • #236 Controlling High Blood Pressure >= 91.07%
    • #110 Preventive Care and Screening: Influenza Immunization >= 91.84%
    • #118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) >= 96.00%
    • #5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) >= 96.55%
    • #128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan >= 97.34%
    • #7 Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) >= 97.92%
    • #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented >= 98.88%
    • #119 Diabetes: Medical Attention for Nephropathy >= 99.71%
    • #178 Rheumatoid Arthritis (RA): Functional Status Assessment >= 99.72%
    • #122 Adult Kidney Disease: Blood Pressure Management >= 99.75%
  • Example of inverse MIPS quality measures which give 10 points with performances higher than 0%:
    • #1 Diabetes: Hemoglobin A1c Poor Control <= 10.32%>
    • #164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation <=  1.82%
  • Examples of measures that are not topped-out and have benchmarks that could be reported by an internist:
    • Measure #1 (Diabetes A1C) - High Priority Measure

      • 3 Points 83.10 - 68.19 %
      • 4 Points 68.18 - 53.14 %
      • 5 Points 53.13 - 40.66 %
      • 6 Points 40.65 - 30.20 %
      • 7 Points 30.19 - 22.74 %  - For example, 30% performance will get the provider 7 points. Please note this is an inverse measure.
      • 8 Points 22.73 - 16.82 %
      • 9 Points 16.81 - 10.33 %
      • 10 Points <= 10.32 %
    • Measure #48 Urinary Incontinence

      • 3 Points 16.31 - 29.03 %
      • 4 Points 29.04 - 42.90 %
      • 5 Points 42.91 - 57.07 %
      • 6 Points 57.08 - 76.52 %
      • 7 Points 76.53 - 89.12 % -  For example, 77% performance will get the provider 7 points.
      • 8 Points 89.13 - 96.91 %
      • 9 Points 96.92 - 99.99 %
      • 10 Points 100 %
    • Measure #112 Breast Cancer Screening

      • 3 Points 14.49 - 24.52 %
      • 4 Points 24.53 - 35.70 %
      • 5 Points 35.71 - 46.01 %
      • 6 Points 46.02 - 55.06 %
      • 7 Points 55.07 - 63.67 % -  For example, 56% performance will get the provider 7 points.
      • 8 Points 63.68 - 74.06 %
      • 9 Points 74.07 - 87.92 %
      • 10 Points 87.93 % -  For example, 88% performance will get the provider 10 points.
    • Measure #236 Controlling High Blood Pressure - Outcome Measure

      • 3 Points 51.00 -58.20 %
      • 4 Points 58.21 - 63.56 %
      • 5 Points 63.57 - 68.27 %
      • 6 Points 68.28 - 72.40 %
      • 7 Points 72.41 - 76.69 % -  For example, 73% performance will get the provider 7 points.
      • 8 Points 76.70 - 82.75 %
      • 9 Points 82.76 - 91.06 %
      • 10 Points 91.07%
  • Examples of measures that are not topped-out and have benchmarks that could be reported by a cardiologist:
    1. Measure# 5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

          • 3 Points 75.86 - 79.58%
          • 4 Points 79.49 - 82.13 %
          • 5 Points 82.14 - 84.99 %
          • 6 Points 85.00-87.49 %
          • 7 Points 87.50 - 89.99 %  - For example, 88% performance will get the provider 7 points.
          • 8 Points 90.00 - 93.53%
          • 9 Points 93.54 - 96.54 %
          • 10 Points 96.55 %
        • Measure #8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Add

          • 3 Points 76.58 - 81.07 %
          • 4 Points 81.08 - 85.57 %
          • 5 Points 85.58 - 88.43 %
          • 6 Points 88.44 - 91.16 %
          • 7 Points 91.17 - 94.28 % -  For example, 92% performance will get the provider 7 points.
          • 8 Points 94.29 - 96..36 %
          • 9 Points 96.37 - 99.99 %
          • 10 Points 100 %
        • Measure #118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

          • 3 Points 71.03 - 74.18 %
          • 4 Points 74.19 - 76.51 %
          • 5 Points 76.52 - 78.94 %
          • 6 Points 78.95 - 81.10%
          • 7 Points 81.11 - 83.99 % -  For example, 82% performance will get the provider 7 points.
          • 8 Points 84.00 - 87.79 %
          • 9 Points 8780 - 95.99 %
          • 10 Points 96.00 %
        • Measure #326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

          • 3 Points 20.00 - 30.18%
          • 4 Points 39.19 - 52.33 %
          • 5 Points 52.34 - 69.56 %
          • 6 Points 69.57 - 76.18 %
          • 7 Points 76.19 - 82.49 % -  For example, 77% performance will get the provider 7 points.
          • 8 Points 82.50 - 94.33 %
          • 9 Points 94.34 - 99.99
          • 10 Points 100.00%
  • Examples of measures that are not topped-out and have benchmarks that could be reported by an allergist/immunologist:
  • Measure# 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    • 3 Points 24.74 - 35.47%
    • 4 Points 35.48 - 47.87%
    • 5 Points 47.88 - 62.14%
    • 6 Points 62.15 - 71.64%
    • 7 Points 71.65-79.36 %  - For example, 72% performance will get the provider 7 points.
    • 8 Points 79.37 - 88.85%
    • 9 Points 88.86 - 98.87%
    • 10 Points 96.55 %
  • Measure #331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Inverse Measure High Priority Measure

    • 3 Points 89.07 - 82.41%
    • 4 Points 82.40 - 71.44 %
    • 5 Points 71.43 - 46.46 %
    • 6 Points 46.45 - 16.91 %
    • 7 Points 16.90 - 0.60 % -  For example, 16% performance will get the provider 7 points.
    • 8 Points 0.59 - 0.01%
    • 9 Points n/a
    • 10 Points 0%
  • Measure #332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) High Priority Measure

    • 3 Points 44.39 - 47.99 %
    • 4 Points 48.00 - 51.88 %
    • 5 Points 51.89 - 57.57%
    • 6 Points 57.58 - 64.99%
    • 7 Points 65.00 - 72.72% -  For example, 65% performance will get the provider 7 points.
    • 8 Points 72.73 - 95.99 %
    • 9 Points 96.00 - 99.99 %
    • 10 Points 100%
  • Measure #402 Tobacco Use and Help with Quitting Among Adolescents

    • 3 Points 74.10 - 82.15 %
    • 4 Points 81.16 - 87.49 %
    • 5 Points 87.50 - 90.37%
    • 6 Points 90.38 - 92.72 %
    • 7 Points 92.73 - 95.15 % -  For example, 93% performance will get the provider 7 points.
    • 8 Points 95.16 - 97.50 %
    • 9 Points 97.51 - 99.99
    • 10 Points 100%
  1. Examples of measures that are not topped-out and have benchmarks that could be reported by an rheumatologist:
  • Measure# 47 Care Plan - High Priority Measure

    • 3 Points 16.52 - 38.11%
    • 4 Points 38.12 - 59.14%
    • 5 Points 59.15 - 74.99%
    • 6 Points 75.00 - 88.71%
    • 7 Points 88.72 - 96.29 %  - For example, an 89% performance will get the provider 7 points.
    • 8 Points 96.30 - 99.17%
    • 9 Points 99.18 - 99.99%
    • 10 Points 100%
  • Measure #178 Rheumatoid Arthritis (RA): Functional Status Assessment

    • 3 Points 27.99 - 45.95%
    • 4 Points 45.96 - 64.17 %
    • 5 Points 64.18 - 74.46 %
    • 6 Points 7.47 - 81.36 %
    • 7 Points 81.37 - 87.82% -  For example, 82% performance will get the provider 7 points.
    • 8 Points 87.83 - 92.34%
    • 9 Points 92.35 - 99.71
    • 10 Points 100%
  • Measure #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    • 3 Points 24.74 - 35.47 %
    • 4 Points 35.48 - 47.87 %
    • 5 Points 47.88 - 62.14%
    • 6 Points 62.15 - 71.64%
    • 7 Points 71.65 - 79.36% -  For example, 72% performance will get the provider 7 points.
    • 8 Points 79.37 - 88.85 %
    • 9 Points 88.86 - 98.87 %
    • 10 Points 98.88%
ID:

001
NQF:

0059
eMeasure ID:

CMS122v6
High Priority:

Yes

#001: Diabetes: Hemoglobin A1c Poor Control

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Nephrology
  • Preventive Medicine
ID:

005
NQF:

0081
eMeasure ID:

CMS135v6
High Priority:

No

#005: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

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 therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Hospitalists
  • Internal Medicine
ID:

006
NQF:

0067
eMeasure ID:
High Priority:

No

#006: Coronary Artery Disease (CAD): Antiplatelet Therapy

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

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
ID:

007
NQF:

0070
eMeasure ID:

CMS145v6
High Priority:

No

#007: Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)

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

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
ID:

008
NQF:

0083
eMeasure ID:

CMS144v6
High Priority:

No

#008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

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

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Hospitalists
  • Internal Medicine
ID:

009
NQF:

0105
eMeasure ID:

CMS128v6
High Priority:

No

#009: Anti-Depressant Medication Management

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: 

  1. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) 
  2. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
     
Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:

012
NQF:

0086
eMeasure ID:

CMS143v6
High Priority:

No

#012: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

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 office visits within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:

014
NQF:

0087
eMeasure ID:
High Priority:

No

#014: Age-Related Macular Degeneration (AMD): Dilated Macular Examination

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:

018
NQF:

0088
eMeasure ID:

CMS167v6
High Priority:

No

#018: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:

019
NQF:

0089
eMeasure ID:

CMS142v6
High Priority:

Yes

#019: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

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 within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:

021
NQF:

0268
eMeasure ID:
High Priority:

No

#021: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin

Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis

Measure Type
  • Process
Specifications
Specialty
  • General Surgery
  • Neurosurgery
  • Orthopedic Surgery
  • Otolaryngology
  • Plastic Surgery
  • Thoracic Surgery
  • Vascular Surgery
ID:

023
NQF:

0239
eMeasure ID:
High Priority:

Yes

#023: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

Measure Type
  • Process
Specifications
Specialty
  • General Surgery
  • Neurosurgery
  • Orthopedic Surgery
  • Otolaryngology
  • Plastic Surgery
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

024
NQF:

0045
eMeasure ID:
High Priority:

Yes

#024: Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older

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 reported by the physician who treats the fracture and who therefore is held accountable for the communication

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Orthopedic Surgery
  • Preventive Medicine
  • Rheumatology
ID:

039
NQF:

0046
eMeasure ID:
High Priority:

No

#039: Screening for Osteoporosis for Women Aged 65-85 Years of Age

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

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Preventive Medicine
  • Rheumatology
ID:

043
NQF:

0134
eMeasure ID:
High Priority:

No

#043: Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft.

Measure Type
  • Process
Specifications
Specialty
  • Thoracic Surgery
ID:

044
NQF:

0236
eMeasure ID:
High Priority:

No

#044: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery

Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:

046
NQF:

0097
eMeasure ID:
High Priority:

Yes

#046: Medication Reconciliation Post-Discharge

The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group: 

  • Reporting Criteria 1: 18-64 years of age
  • Reporting Criteria 2: 65 years and older
  • Total Rate: All patients 18 years of age and older
Measure Type
  • Process
Specifications
Specialty
  • General Surgery
  • Nephrology
  • Orthopedic Surgery
ID:

047
NQF:

0326
eMeasure ID:
High Priority:

Yes

#047: Care Plan

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

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • General Surgery
  • Hospitalists
  • Internal Medicine
  • Neurology
  • Obstetrics/Gynecology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

048
NQF:
eMeasure ID:
High Priority:

No

#048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Obstetrics/Gynecology
  • Preventive Medicine
  • Urology
ID:

050
NQF:
eMeasure ID:
High Priority:

Yes

#050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

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

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Obstetrics/Gynecology
  • Urology
ID:

051
NQF:

0091
eMeasure ID:
High Priority:

No

#051: Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

052
NQF:

0102
eMeasure ID:
High Priority:

No

#052: Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy

Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed an long-acting inhaled bronchodilator

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

065
NQF:

0069
eMeasure ID:

CMS154v6
High Priority:

Yes

#065: Appropriate Treatment for Children with Upper Respiratory Infection (URI)

Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Otolaryngology
  • Pediatrics
ID:

066
NQF:
eMeasure ID:

CMS146v6
High Priority:

Yes

#066: Appropriate Testing for Children with Pharyngitis

Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Pediatrics
ID:

067
NQF:

0377
eMeasure ID:
High Priority:

No

#067: Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow

Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

068
NQF:

0378
eMeasure ID:
High Priority:

No

#068: Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy

Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

069
NQF:

0380
eMeasure ID:
High Priority:

No

#069: Hematology: Multiple Myeloma: Treatment with Bisphosphonates

Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

070
NQF:

0379
eMeasure ID:
High Priority:

No

#070: Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry

Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

076
NQF:
eMeasure ID:
High Priority:

Yes

#076: Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
  • Hospitalists
  • Interventional Radiology
ID:

091
NQF:

0653
eMeasure ID:
High Priority:

Yes

#091: Acute Otitis Externa (AOE): Topical Therapy

Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Otolaryngology
  • Pediatrics
ID:

093
NQF:

0654
eMeasure ID:
High Priority:

Yes

#093: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use

Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Otolaryngology
  • Pediatrics
ID:

099
NQF:

0391
eMeasure ID:
High Priority:

No

#099: Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:

100
NQF:

0392
eMeasure ID:
High Priority:

No

#100: Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:

102
NQF:

0389
eMeasure ID:

CMS129v7
High Priority:

No

#102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

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, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer

Measure Type
  • Process
Specifications
Specialty
  • General Oncology
  • Radiation Oncology
  • Urology
ID:

104
NQF:

0390
eMeasure ID:
High Priority:

No

#104: Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer

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 adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist)

Measure Type
  • Process
Specifications
Specialty
  • Urology
ID:

107
NQF:

0104
eMeasure ID:

CMS161v6
High Priority:

No

#107: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Mental/Behavioral Health
ID:

109
NQF:
eMeasure ID:
High Priority:

Yes

#109: Osteoarthritis (OA): Function and Pain Assessment

Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Orthopedic Surgery
  • Physical Medicine
  • Preventive Medicine
ID:

110
NQF:

0041
eMeasure ID:

CMS147v7
High Priority:

No

#110: Preventive Care and Screening: Influenza Immunization

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Family Medicine
  • Infectious Disease
  • Nephrology
  • Obstetrics/Gynecology
  • Otolaryngology
  • Pediatrics
  • Preventive Medicine
  • Rheumatology
ID:

111
NQF:

0043
eMeasure ID:

CMS127v6
High Priority:

No

#111: Pneumococcal Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Family Medicine
  • Infectious Disease
  • Nephrology
  • Otolaryngology
  • Preventive Medicine
  • Rheumatology
ID:

112
NQF:

2372
eMeasure ID:

CMS125v6
High Priority:

No

#112: Breast Cancer Screening

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Obstetrics/Gynecology
  • Preventive Medicine
ID:

113
NQF:

0034
eMeasure ID:

CMS130v6
High Priority:

No

#113: Colorectal Cancer Screening

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Preventive Medicine
ID:

116
NQF:

0058
eMeasure ID:
High Priority:

Yes

#116: Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Preventive Medicine
ID:

117
NQF:

0055
eMeasure ID:

CMS131v6
High Priority:

No

#117: Diabetes: Eye Exam

Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Ophthalmology
ID:

118
NQF:

0066
eMeasure ID:
High Priority:

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%)

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

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
ID:

119
NQF:

0062
eMeasure ID:

CMS134v6
High Priority:

No

#119: Diabetes: Medical Attention for Nephropathy

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Nephrology
  • Preventive Medicine
  • Urology
ID:

122
NQF:
eMeasure ID:
High Priority:

Yes

#122: Adult Kidney Disease: Blood Pressure Management

Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • N/A
ID:

126
NQF:

0417
eMeasure ID:
High Priority:

No

#126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation

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

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Podiatry
  • Preventive Medicine
ID:

127
NQF:

0416
eMeasure ID:
High Priority:

No

#127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear

Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing

Measure Type
  • Process
Specifications
Specialty
  • Podiatry
ID:

128
NQF:

0421
eMeasure ID:

CMS69v6
High Priority:

No

#128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Gastroenterology
  • General Surgery
  • Infectious Disease
  • Internal Medicine
  • Mental/Behavioral Health
  • Obstetrics/Gynecology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Podiatry
  • Preventive Medicine
  • Rheumatology
  • Urology
  • Vascular Surgery
ID:

130
NQF:

0419
eMeasure ID:

CMS68v7
High Priority:

Yes

#130: Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Dermatology
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • General Surgery
  • Hospitalists
  • Infectious Disease
  • Internal Medicine
  • Mental/Behavioral Health
  • Nephrology
  • Neurology
  • Neurosurgery
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Plastic Surgery
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

131
NQF:

0420
eMeasure ID:
High Priority:

Yes

#131: Pain Assessment and Follow-Up

Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
  • Physical Medicine
  • Rheumatology
  • Urology
ID:

134
NQF:

0418
eMeasure ID:

CMS2v7
High Priority:

No

#134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
  • Orthopedic Surgery
  • Pediatrics
  • Preventive Medicine
ID:

137
NQF:

0650
eMeasure ID:
High Priority:

Yes

#137: Melanoma: Continuity of Care – Recall System

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
Measure Type
  • Structure
Specifications
Specialty
  • Dermatology
ID:

138
NQF:
eMeasure ID:
High Priority:

Yes

#138: Melanoma: Coordination of Care

Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
ID:

140
NQF:

0566
eMeasure ID:
High Priority:

No

#140: Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD

Measure Type
  • Process
Specifications
Specialty
  • Ophthalmology
ID:

141
NQF:

0563
eMeasure ID:
High Priority:

Yes

#141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

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 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within 12 months

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

143
NQF:

0384
eMeasure ID:

CMS157v6
High Priority:

Yes

#143: Oncology: Medical and Radiation – Pain Intensity Quantified

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

Measure Type
  • Process
Specifications
Specialty
  • General Oncology
  • Radiation Oncology
ID:

144
NQF:

0383
eMeasure ID:
High Priority:

Yes

#144: Oncology: Medical and Radiation – Plan of Care for Pain

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

Measure Type
  • Process
Specifications
Specialty
  • General Oncology
  • Radiation Oncology
ID:

145
NQF:
eMeasure ID:
High Priority:

Yes

#145: Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy

Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
  • Interventional Radiology
ID:

146
NQF:

0508
eMeasure ID:
High Priority:

Yes

#146: Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms

Percentage of final reports for screening mammograms that are classified as "probably benign"

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

147
NQF:
eMeasure ID:
High Priority:

Yes

#147: Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

154
NQF:

0101
eMeasure ID:
High Priority:

Yes

#154: Falls: Risk Assessment

Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Neurology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Podiatry
  • Preventive Medicine
ID:

155
NQF:

0101
eMeasure ID:
High Priority:

Yes

#155: Falls: Plan of Care

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

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Neurology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Podiatry
  • Preventive Medicine
ID:

156
NQF:

0382
eMeasure ID:
High Priority:

No

#156: Oncology: Radiation Dose Limits to Normal Tissues

Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

Measure Type
  • Process
Specifications
Specialty
  • Radiation Oncology
ID:

160
NQF:

0405
eMeasure ID:

CMS52v6
High Priority:

No

#160: HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis

Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Pediatrics
ID:

163
NQF:

0056
eMeasure ID:

CMS123v6
High Priority:

No

#163: Diabetes: Foot Exam

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
ID:

164
NQF:

0129
eMeasure ID:
High Priority:

Yes

#164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:

165
NQF:

0130
eMeasure ID:
High Priority:

Yes

#165: Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:

166
NQF:

0131
eMeasure ID:
High Priority:

Yes

#166: Coronary Artery Bypass Graft (CABG): Stroke

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:

167
NQF:

0114
eMeasure ID:
High Priority:

Yes

#167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

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

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:

168
NQF:

0115
eMeasure ID:
High Priority:

Yes

#168: Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

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

Measure Type
  • Outcome
Specifications
Specialty
  • Thoracic Surgery
ID:

176
NQF:
eMeasure ID:
High Priority:

No

#176: Rheumatoid Arthritis (RA): Tuberculosis Screening

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)

Measure Type
  • Process
Specifications
Specialty
  • Infectious Disease
  • Rheumatology
ID:

177
NQF:
eMeasure ID:
High Priority:

No

#177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Rheumatology
ID:

178
NQF:
eMeasure ID:
High Priority:

No

#178: Rheumatoid Arthritis (RA): Functional Status Assessment

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

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
  • Rheumatology
ID:

179
NQF:
eMeasure ID:
High Priority:

No

#179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
  • Rheumatology
ID:

180
NQF:
eMeasure ID:
High Priority:

No

#180: Rheumatoid Arthritis (RA): Glucocorticoid Management

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 >= 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
  • Rheumatology
ID:

181
NQF:
eMeasure ID:
High Priority:

Yes

#181: Elder Maltreatment Screen and Follow-Up Plan

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:

182
NQF:

2624
eMeasure ID:
High Priority:

Yes

#182: Functional Outcome Assessment

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

Measure Type
  • Process
Specifications
Specialty
  • Physical Medicine
ID:

185
NQF:

0659
eMeasure ID:
High Priority:

Yes

#185: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:

187
NQF:
eMeasure ID:
High Priority:

No

#187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Neurosurgery
ID:

191
NQF:

0565
eMeasure ID:

CMS133v6
High Priority:

Yes

#191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery 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 within 90 days following the cataract surgery

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

192
NQF:

0564
eMeasure ID:

CMS132v6
High Priority:

Yes

#192: Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

195
NQF:

0507
eMeasure ID:
High Priority:

No

#195: Radiology: Stenosis Measurement in Carotid Imaging Reports

Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

204
NQF:

0068
eMeasure ID:

CMS164v6
High Priority:

No

#204: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
ID:

205
NQF:

0409
eMeasure ID:
High Priority:

No

#205: HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection

Measure Type
  • Process
Specifications
Specialty
  • Infectious Disease
  • Pediatrics
ID:

217
NQF:

0422
eMeasure ID:
High Priority:

Yes

#217: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments

A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

218
NQF:

0423
eMeasure ID:
High Priority:

Yes

#218: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments

A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

219
NQF:

0424
eMeasure ID:
High Priority:

Yes

#219: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments

A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

220
NQF:

0425
eMeasure ID:
High Priority:

Yes

#220: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments

A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

221
NQF:

0426
eMeasure ID:
High Priority:

Yes

#221: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments

A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

222
NQF:

0427
eMeasure ID:
High Priority:

Yes

#222: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments

A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

223
NQF:

0428
eMeasure ID:
High Priority:

Yes

#223: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments

A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

224
NQF:

0562
eMeasure ID:
High Priority:

Yes

#224: Melanoma: Overutilization of Imaging Studies in Melanoma

Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
ID:

225
NQF:

0509
eMeasure ID:
High Priority:

Yes

#225: Radiology: Reminder System for Screening Mammograms

Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram

Measure Type
  • Structure
Specifications
Specialty
  • Diagnostic Radiology
ID:

226
NQF:

0028
eMeasure ID:

CMS138v6
High Priority:

No

#226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Dermatology
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • General Surgery
  • Infectious Disease
  • Internal Medicine
  • Mental/Behavioral Health
  • Neurology
  • Neurosurgery
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Plastic Surgery
  • Podiatry
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

236
NQF:

0018
eMeasure ID:

CMS165v6
High Priority:

Yes

#236: Controlling High Blood Pressure

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Cardiology
  • Obstetrics/Gynecology
  • Rheumatology
  • Thoracic Surgery
  • Vascular Surgery
ID:

238
NQF:

0022
eMeasure ID:

CMS156v6
High Priority:

Yes

#238: Use of High-Risk Medications in the Elderly

Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Rheumatology
ID:

239
NQF:

0024
eMeasure ID:

CMS155v6
High Priority:

No

#239: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

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. Three rates are reported.

  1.  Percentage of patients with height, weight, and body mass  index (BMI) percentile documentation
  2.  Percentage of patients with counseling for nutrition
  3.  Percentage of patients with counseling for physical activity
Measure Type
  • Process
Specifications
Specialty
  • Pediatrics
ID:

240
NQF:

0038
eMeasure ID:

CMS117v6
High Priority:

No

#240: Childhood Immunization Status

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 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

Measure Type
  • Process
Specifications
Specialty
  • Pediatrics
ID:

243
NQF:

0643
eMeasure ID:
High Priority:

Yes

#243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting

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

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
ID:

249
NQF:

1854
eMeasure ID:
High Priority:

No

#249: Barrett's Esophagus

Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia

Measure Type
  • Process
Specifications
Specialty
  • Pathology
ID:

250
NQF:

1853
eMeasure ID:
High Priority:

No

#250: Radical Prostatectomy Pathology Reporting

Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status

Measure Type
  • Process
Specifications
Specialty
  • General Oncology
  • Pathology
ID:

251
NQF:

1855
eMeasure ID:
High Priority:

No

Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients

This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer

Measure Type
  • Structure
Specifications
Specialty
  • Pathology
ID:

254
NQF:

0651
eMeasure ID:
High Priority:

No

#254: Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain

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

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
ID:

255
NQF:
eMeasure ID:
High Priority:

No

#255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure

Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED)

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
ID:

257
NQF:

1519
eMeasure ID:
High Priority:

No

#257: Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge

Measure Type
  • Process
Specifications
Specialty
  • Vascular Surgery
ID:

258
NQF:
eMeasure ID:
High Priority:

Yes

#258: Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)

Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)

Measure Type
  • Outcome
Specifications
Specialty
  • Vascular Surgery
ID:

259
NQF:
eMeasure ID:
High Priority:

Yes

#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)

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)

Measure Type
  • Outcome
Specifications
Specialty
  • Vascular Surgery
ID:

260
NQF:
eMeasure ID:
High Priority:

Yes

#260: Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)

Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2

Measure Type
  • Outcome
Specifications
Specialty
  • Vascular Surgery
ID:

261
NQF:
eMeasure ID:
High Priority:

Yes

#261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

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

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

262
NQF:
eMeasure ID:
High Priority:

Yes

#262: Image Confirmation of Successful Excision of Image-Localized Breast Lesion

Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

263
NQF:
eMeasure ID:
High Priority:

No

#263: Preoperative Diagnosis of Breast Cancer

The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

264
NQF:
eMeasure ID:
High Priority:

No

#264: Sentinel Lymph Node Biopsy for Invasive Breast Cancer

The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

265
NQF:
eMeasure ID:
High Priority:

Yes

#265: Biopsy Follow-Up

Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
  • Obstetrics/Gynecology
  • Otolaryngology
  • Urology
ID:

268
NQF:

1814
eMeasure ID:
High Priority:

No

#268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:

271
NQF:
eMeasure ID:
High Priority:

No

#271: Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury

Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:

275
NQF:
eMeasure ID:
High Priority:

No

#275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
  • Infectious Disease
ID:

276
NQF:
eMeasure ID:
High Priority:

No

#276: Sleep Apnea: Assessment of Sleep Symptoms

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness

Measure Type
  • Process
Specifications
Specialty
  • Otolaryngology
ID:

277
NQF:
eMeasure ID:
High Priority:

No

#277: Sleep Apnea: Severity Assessment at Initial Diagnosis

Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

Measure Type
  • Process
Specifications
Specialty
  • Otolaryngology
ID:

278
NQF:
eMeasure ID:
High Priority:

No

#278: Sleep Apnea: Positive Airway Pressure Therapy Prescribed

Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy

Measure Type
  • Process
Specifications
Specialty
  • Otolaryngology
ID:

279
NQF:
eMeasure ID:
High Priority:

No

#279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured

Measure Type
  • Process
Specifications
Specialty
  • Otolaryngology
ID:

281
NQF:

2872
eMeasure ID:

CMS149v6
High Priority:

No

#281: Dementia: Cognitive Assessment

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

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Neurology
ID:

282
NQF:
eMeasure ID:
High Priority:

No

#282: Dementia: Functional Status Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Neurology
ID:

283
NQF:
eMeasure ID:
High Priority:

No

#283: Dementia: Neuropsychiatric Symptom Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Neurology
ID:

286
NQF:
eMeasure ID:
High Priority:

Yes

#286: Dementia: Counseling Regarding Safety Concerns

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Neurology
ID:

288
NQF:
eMeasure ID:
High Priority:

Yes

#288: Dementia: Caregiver Education and Support

Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Neurology
ID:

290
NQF:
eMeasure ID:
High Priority:

No

#290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease

All patients with a diagnosis of Parkinson's disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:

291
NQF:
eMeasure ID:
High Priority:

No

#291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment

All patients with a diagnosis of Parkinson's disease who were assessed for cognitive impairment or dysfunction in the last 12 months

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:

293
NQF:
eMeasure ID:
High Priority:

Yes

#293: Parkinson’s Disease: Rehabilitative Therapy Options

All patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:

303
NQF:

1536
eMeasure ID:
High Priority:

Yes

#303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

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

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

304
NQF:
eMeasure ID:
High Priority:

Yes

#304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

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

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

305
NQF:

0004
eMeasure ID:

CMS137v6
High Priority:

No

#305: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.

  1. Percentage of patients who initiated treatment within 14 days of the diagnosis
  2. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit
     
Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Pediatrics
ID:

309
NQF:

0032
eMeasure ID:

CMS124v6
High Priority:

No

#309: Cervical Cancer Screening

 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 every 3 years
  • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Obstetrics/Gynecology
ID:

310
NQF:

0033
eMeasure ID:

CMS153v6
High Priority:

No

#310: Chlamydia Screening for Women

Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period

Measure Type
  • Process
Specifications
Specialty
  • Obstetrics/Gynecology
  • Pediatrics
ID:

317
NQF:
eMeasure ID:

CMS22v6
High Priority:

No

#317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Dermatology
  • Emergency Medicine
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • General Surgery
  • Internal Medicine
  • Mental/Behavioral Health
  • Nephrology
  • Neurology
  • Obstetrics/Gynecology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Plastic Surgery
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

318
NQF:

0101
eMeasure ID:

CMS139v6
High Priority:

No

#318: Falls: Screening for Future Fall Risk

Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period

Measure Type
  • Process
Specifications
Specialty
  • Nephrology
  • Orthopedic Surgery
ID:

320
NQF:

0658
eMeasure ID:
High Priority:

Yes

#320: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:

322
NQF:
eMeasure ID:
High Priority:

Yes

#322: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients

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 reporting period

Measure Type
  • Efficiency
Specifications
Specialty
  • Cardiology
ID:

323
NQF:
eMeasure ID:
High Priority:

Yes

#323: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)

Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status

Measure Type
  • Efficiency
Specifications
Specialty
  • Cardiology
ID:

324
NQF:
eMeasure ID:
High Priority:

Yes

#324: Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment

Measure Type
  • Efficiency
Specifications
Specialty
  • Cardiology
ID:

325
NQF:
eMeasure ID:
High Priority:

Yes

#325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
ID:

326
NQF:

1525
eMeasure ID:
High Priority:

No

#326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
ID:

327
NQF:
eMeasure ID:
High Priority:

Yes

#327: Pediatric Kidney Disease: Adequacy of Volume Management

Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

328
NQF:

1667
eMeasure ID:
High Priority:

Yes

#328: Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL

Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • N/A
ID:

329
NQF:
eMeasure ID:
High Priority:

Yes

#329: Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis

Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

330
NQF:
eMeasure ID:
High Priority:

Yes

#330: Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days

Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

331
NQF:
eMeasure ID:
High Priority:

No

#331: Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)

Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Otolaryngology
ID:

332
NQF:
eMeasure ID:
High Priority:

No

#332: Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

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

Measure Type
  • Process
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Otolaryngology
ID:

333
NQF:
eMeasure ID:
High Priority:

No

#333: Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)

Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis

Measure Type
  • Efficiency
Specifications
Specialty
  • Emergency Medicine
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Otolaryngology
ID:

334
NQF:
eMeasure ID:
High Priority:

No

#334: Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)

Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis

Measure Type
  • Efficiency
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Otolaryngology
ID:

335
NQF:
eMeasure ID:
High Priority:

Yes

#335: Maternity Care: Elective Delivery or Early Induction Without Medical Indication at = 37 and < 39 Weeks (Overuse)

Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at >= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

336
NQF:
eMeasure ID:
High Priority:

Yes

#336: Maternity Care: Post-Partum Follow-Up and Care Coordination

Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

337
NQF:
eMeasure ID:
High Priority:

No

#337: Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier

Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
ID:

338
NQF:

2082
eMeasure ID:
High Priority:

Yes

#338: HIV Viral Load Suppression

The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year

Measure Type
  • Outcome
Specifications
Specialty
  • Allergy/Immunology
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
ID:

340
NQF:

2079
eMeasure ID:
High Priority:

Yes

#340: HIV Medical Visit Frequency

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

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Infectious Disease
ID:

342
NQF:
eMeasure ID:
High Priority:

Yes

#342: Pain Brought Under Control Within 48 Hours

Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours

Measure Type
  • Outcome
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
ID:

343
NQF:
eMeasure ID:
High Priority:

Yes

#343: Screening Colonoscopy Adenoma Detection Rate

The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy

Measure Type
  • Outcome
Specifications
Specialty
  • Gastroenterology
ID:

344
NQF:
eMeasure ID:
High Priority:

Yes

#344: Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)

Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2

Measure Type
  • Outcome
Specifications
Specialty
  • Cardiology
  • Vascular Surgery
ID:

345
NQF:

1543
eMeasure ID:
High Priority:

Yes

#345: Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive

Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital

Measure Type
  • Outcome
Specifications
Specialty
  • Cardiology
  • Neurosurgery
  • Vascular Surgery
ID:

346
NQF:

1540
eMeasure ID:
High Priority:

Yes

#346: Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive

Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital

Measure Type
  • Outcome
Specifications
Specialty
  • Neurosurgery
  • Vascular Surgery
ID:

347
NQF:

1534
eMeasure ID:
High Priority:

Yes

#347: Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive

Percent of patients undergoing endovascular repair of small or moderate infrarenal abdominal aortic aneurysms (AAA) that die while in the hospital

Measure Type
  • Outcome
Specifications
Specialty
  • Vascular Surgery
ID:

348
NQF:
eMeasure ID:
High Priority:

Yes

#348: HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate

Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD

Measure Type
  • Outcome
Specifications
Specialty
  • Electrophysiology Cardiac Specialist
ID:

350
NQF:
eMeasure ID:
High Priority:

Yes

#350: Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

Percentage of patients regardless of age undergoing a total knee 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

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:

351
NQF:
eMeasure ID:
High Priority:

Yes

#351: Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

Percentage of patients regardless of age undergoing a total knee 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)

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:

352
NQF:
eMeasure ID:
High Priority:

Yes

#352: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet

Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:

353
NQF:
eMeasure ID:
High Priority:

Yes

#353: Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report

Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:

354
NQF:
eMeasure ID:
High Priority:

Yes

#354: Anastomotic Leak Intervention

Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery

Measure Type
  • Outcome
Specifications
Specialty
  • N/A
ID:

355
NQF:
eMeasure ID:
High Priority:

Yes

#355: Unplanned Reoperation within the 30 Day Postoperative Period

Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period

Measure Type
  • Outcome
Specifications
Specialty
  • General Surgery
  • Plastic Surgery
ID:

356
NQF:
eMeasure ID:
High Priority:

Yes

#356: Unplanned Hospital Readmission within 30 Days of Principal Procedure

Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure

Measure Type
  • Outcome
Specifications
Specialty
  • General Surgery
  • Plastic Surgery
ID:

357
NQF:
eMeasure ID:
High Priority:

Yes

#357: Surgical Site Infection (SSI)

Percentage of patients aged 18 years and older who had a surgical site infection (SSI)

Measure Type
  • Outcome
Specifications
Specialty
  • General Surgery
  • Otolaryngology
  • Plastic Surgery
  • Vascular Surgery
ID:

358
NQF:
eMeasure ID:
High Priority:

Yes

#358: Patient-centered Surgical Risk Assessment and Communication

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

Measure Type
  • Process
Specifications
Specialty
  • General Surgery
  • Orthopedic Surgery
  • Otolaryngology
  • Plastic Surgery
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

359
NQF:
eMeasure ID:
High Priority:

Yes

#359: Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description

Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution's computer systems

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

360
NQF:
eMeasure ID:
High Priority:

Yes

#360: Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

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

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

361
NQF:
eMeasure ID:
High Priority:

Yes

#361: Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry

Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements

Measure Type
  • Structure
Specifications
Specialty
  • Diagnostic Radiology
ID:

362
NQF:
eMeasure ID:
High Priority:

Yes

#362: Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes

Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study

Measure Type
  • Structure
Specifications
Specialty
  • Diagnostic Radiology
ID:

363
NQF:
eMeasure ID:
High Priority:

Yes

#363: Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive

Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

Measure Type
  • Structure
Specifications
Specialty
  • Diagnostic Radiology
ID:

364
NQF:
eMeasure ID:
High Priority:

Yes

#364: Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines

Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

366
NQF:

0108
eMeasure ID:

CMS136v7
High Priority:

No

#366: Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care.  Two rates are reported.  

  1. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase
  2. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended
     
Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Pediatrics
ID:

367
NQF:
eMeasure ID:

CMS169v6
High Priority:

No

#367: Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
ID:

369
NQF:
eMeasure ID:

CMS158v6
High Priority:

No

#369: Pregnant women that had HBsAg testing

This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy

Measure Type
  • Process
Specifications
Specialty
  • Obstetrics/Gynecology
ID:

370
NQF:

0710
eMeasure ID:

CMS159v6
High Priority:

Yes

#370: Depression Remission at Twelve Months

Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

Measure Type
  • Outcome
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:

371
NQF:

0712
eMeasure ID:

CMS160v6
High Priority:

No

#371: Depression Utilization of the PHQ-9 Tool

The percentage of patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during  each applicable 4 month period in which there was a qualifying visit

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:

372
NQF:
eMeasure ID:

CMS82v5
High Priority:

No

#372: Maternal Depression Screening

The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

373
NQF:
eMeasure ID:

CMS65v7
High Priority:

Yes

#373: Hypertension: Improvement in Blood Pressure

Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
ID:

374
NQF:
eMeasure ID:

CMS50v6
High Priority:

Yes

#374: Closing the Referral Loop: Receipt of Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Dermatology
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • General Surgery
  • Internal Medicine
  • Interventional Radiology
  • Mental/Behavioral Health
  • Neurology
  • Obstetrics/Gynecology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery
ID:

375
NQF:
eMeasure ID:

CMS66v6
High Priority:

Yes

#375: Functional Status Assessment for Total Knee Replacement

Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:

376
NQF:
eMeasure ID:

CMS56v6
High Priority:

Yes

#376: Functional Status Assessment for Total Hip Replacement

Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

Measure Type
  • Process
Specifications
Specialty
  • Orthopedic Surgery
ID:

377
NQF:
eMeasure ID:

CMS90v7
High Priority:

Yes

#377: Functional Status Assessments for Congestive Heart Failure

Percentage of patients 18 years of age and older with congestive  heart failure who completed initial and follow-up patient-reported functional status assessments

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
ID:

378
NQF:
eMeasure ID:

CMS75v6
High Priority:

Yes

#378: Children Who Have Dental Decay or Cavities

Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period

Measure Type
  • Outcome
Specifications
Specialty
  • Dentistry
ID:

379
NQF:
eMeasure ID:

CMS74v7
High Priority:

No

#379: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists

Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period

Measure Type
  • Process
Specifications
Specialty
  • Dentistry
  • Pediatrics
ID:

382
NQF:

1365
eMeasure ID:

CMS177v6
High Priority:

Yes

#382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

 Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Pediatrics
ID:

383
NQF:

1879
eMeasure ID:
High Priority:

Yes

#383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Percentage of individuals at least 18 years of age as of the beginning of the measurement 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 measurement period (12 consecutive months)

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Mental/Behavioral Health
ID:

384
NQF:
eMeasure ID:
High Priority:

Yes

#384: Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

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

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

385
NQF:
eMeasure ID:
High Priority:

Yes

#385: Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

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

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

386
NQF:
eMeasure ID:
High Priority:

Yes

#386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

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, hospice) at least once annually

Measure Type
  • Process
Specifications
Specialty
  • Neurology
ID:

387
NQF:

3060
eMeasure ID:
High Priority:

No

#387: Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
ID:

388
NQF:
eMeasure ID:
High Priority:

Yes

#388: Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)

Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

389
NQF:
eMeasure ID:
High Priority:

Yes

#389: Cataract Surgery: Difference Between Planned and Final Refraction

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

Measure Type
  • Outcome
Specifications
Specialty
  • Ophthalmology
ID:

390
NQF:
eMeasure ID:
High Priority:

Yes

#390: Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
  • Infectious Disease
ID:

391
NQF:

0576
eMeasure ID:
High Priority:

Yes

#391: Follow-Up After Hospitalization for Mental Illness (FUH)

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: 

  • The percentage of discharges for which the patient received follow-up within 30 days of discharge.
  • The percentage of discharges for which the patient received follow-up within 7 days of discharge
Measure Type
  • Process
Specifications
Specialty
  • Mental/Behavioral Health
  • Pediatrics
ID:

392
NQF:

2474
eMeasure ID:
High Priority:

Yes

#392: HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender: 

  • Reporting Age Criteria 1: Females 18-64years of age
  • Reporting Age Criteria 2: Males 18-64 years of age
  • Reporting Age Criteria 3: Females 65 years of age and older
  • Reporting Age Criteria 4: Males 65 years of age and older
Measure Type
  • Outcome
Specifications
Specialty
  • Electrophysiology Cardiac Specialist
ID:

393
NQF:
eMeasure ID:
High Priority:

Yes

#393: HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

Infection rate following CIED device implantation, replacement, or revision

Measure Type
  • Outcome
Specifications
Specialty
  • Electrophysiology Cardiac Specialist
ID:

394
NQF:

1407
eMeasure ID:
High Priority:

No

#394: Immunizations for Adolescents

The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Pediatrics
ID:

395
NQF:
eMeasure ID:
High Priority:

Yes

#395: Lung Cancer Reporting (Biopsy/Cytology Specimens)

Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report

Measure Type
  • Outcome
Specifications
Specialty
  • Pathology
ID:

396
NQF:
eMeasure ID:
High Priority:

Yes

#396: Lung Cancer Reporting (Resection Specimens)

Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type

Measure Type
  • Outcome
Specifications
Specialty
  • Pathology
ID:

397
NQF:
eMeasure ID:
High Priority:

Yes

#397: Melanoma Reporting

Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate

Measure Type
  • Outcome
Specifications
Specialty
  • Pathology
ID:

398
NQF:
eMeasure ID:
High Priority:

Yes

#398: Optimal Asthma Control

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

Measure Type
  • Outcome
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Otolaryngology
  • Pediatrics
ID:

400
NQF:

3059
eMeasure ID:
High Priority:

No

#400: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk

Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Infectious Disease
  • Internal Medicine
  • Nephrology
ID:

401
NQF:
eMeasure ID:
High Priority:

No

#401: Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis

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 reporting period

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Gastroenterology
  • Infectious Disease
  • Internal Medicine
ID:

402
NQF:
eMeasure ID:
High Priority:

No

#402: Tobacco Use and Help with Quitting Among Adolescents

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

Measure Type
  • Process
Specifications
Specialty
  • Allergy/Immunology
  • Cardiology
  • Dermatology
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • General Surgery
  • Internal Medicine
  • Mental/Behavioral Health
  • Neurology
  • Obstetrics/Gynecology
  • Orthopedic Surgery
  • Otolaryngology
  • Pediatrics
  • Physical Medicine
  • Preventive Medicine
  • Rheumatology
  • Thoracic Surgery
  • Vascular Surgery
ID:

403
NQF:
eMeasure ID:
High Priority:

Yes

#403: Adult Kidney Disease: Referral to Hospice

Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care

Measure Type
  • Process
Specifications
Specialty
  • N/A
ID:

404
NQF:
eMeasure ID:
High Priority:

Yes

#404: Anesthesiology Smoking Abstinence

The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Anesthesiology
ID:

405
NQF:
eMeasure ID:
High Priority:

Yes

#405: Appropriate Follow-up Imaging for Incidental Abdominal Lesions

Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended: 

  • Liver lesion <= 0.5 cm
  • Cystic kidney lesion < 1.0 cm
  • Adrenal lesion <= 1.0 cm
Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

406
NQF:
eMeasure ID:
High Priority:

Yes

#406: Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

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 or ultrasound of the 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

Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

407
NQF:
eMeasure ID:
High Priority:

Yes

#407: Appropriate Treatment of MSSA Bacteremia

Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy

Measure Type
  • Process
Specifications
Specialty
  • Hospitalists
  • Infectious Disease
ID:

408
NQF:
eMeasure ID:
High Priority:

No

#408: Opioid Therapy Follow-up Evaluation

All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Neurology
  • Orthopedic Surgery
  • Physical Medicine
ID:

409
NQF:
eMeasure ID:
High Priority:

Yes

#409: Clinical Outcome Post Endovascular Stroke Treatment

Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention

Measure Type
  • Outcome
Specifications
Specialty
  • Interventional Radiology
  • Neurosurgery
ID:

410
NQF:
eMeasure ID:
High Priority:

Yes

#410: Psoriasis: Clinical Response to Oral Systemic or Biologic Medications

Percentage of psoriasis patients receiving oral systemic or biologic therapy 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

Measure Type
  • Outcome
Specifications
Specialty
  • Dermatology
ID:

411
NQF:

0711
eMeasure ID:
High Priority:

Yes

#411: Depression Remission at Six Months

Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

Measure Type
  • Outcome
Specifications
Specialty
  • Mental/Behavioral Health
ID:

412
NQF:
eMeasure ID:
High Priority:

No

#412: Documentation of Signed Opioid Treatment Agreement

All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Neurology
  • Orthopedic Surgery
  • Physical Medicine
ID:

413
NQF:
eMeasure ID:
High Priority:

Yes

#413: Door to Puncture Time for Endovascular Stroke Treatment

Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours

Measure Type
  • Intermediate Outcome
Specifications
Specialty
  • Interventional Radiology
  • Neurosurgery
ID:

414
NQF:
eMeasure ID:
High Priority:

No

#414: Evaluation or Interview for Risk of Opioid Misuse

All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Neurology
  • Orthopedic Surgery
  • Physical Medicine
ID:

415
NQF:
eMeasure ID:
High Priority:

Yes

#415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT

Measure Type
  • Efficiency
Specifications
Specialty
  • Emergency Medicine
ID:

416
NQF:
eMeasure ID:
High Priority:

Yes

#416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years

Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and 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

Measure Type
  • Efficiency
Specifications
Specialty
  • Emergency Medicine
ID:

417
NQF:

1523
eMeasure ID:
High Priority:

Yes

#417: Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive

Percentage of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive

Measure Type
  • Outcome
Specifications
Specialty
  • Vascular Surgery
ID:

418
NQF:

0053
eMeasure ID:
High Priority:

No

#418: Osteoporosis Management in Women Who Had a Fracture

The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture

Measure Type
  • Process
Specifications
Specialty
  • Family Medicine
  • Internal Medicine
  • Obstetrics/Gynecology
  • Orthopedic Surgery
ID:

419
NQF:
eMeasure ID:
High Priority:

Yes

#419: Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination

Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered

Measure Type
  • Efficiency
Specifications
Specialty
  • Neurology
ID:

420
NQF:
eMeasure ID:
High Priority:

No

#420: Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

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

Measure Type
  • Outcome
Specifications
Specialty
  • Interventional Radiology
  • Vascular Surgery
ID:

421
NQF:
eMeasure ID:
High Priority:

No

#421: Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal

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

Measure Type
  • Process
Specifications
Specialty
  • Interventional Radiology
ID:

422
NQF:

2063
eMeasure ID:
High Priority:

Yes

#422: Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury

Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse

Measure Type
  • Process
Specifications
Specialty
  • Obstetrics/Gynecology
ID:

423
NQF:

0465
eMeasure ID:
High Priority:

No

#423: Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy

Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

Measure Type
  • Process
Specifications
Specialty
  • Vascular Surgery
ID:

424
NQF:

2671
eMeasure ID:
High Priority:

Yes

#424: Perioperative temperature management

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 recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

Measure Type
  • Outcome
Specifications
Specialty
  • Anesthesiology
ID:

425
NQF:
eMeasure ID:
High Priority:

No

#425: Photodocumentation of Cecal Intubation

The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination

Measure Type
  • Process
Specifications
Specialty
  • Gastroenterology
ID:

426
NQF:
eMeasure ID:
High Priority:

Yes

#426: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)

Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:

427
NQF:
eMeasure ID:
High Priority:

Yes

#427: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:

428
NQF:
eMeasure ID:
High Priority:

No

#428: Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence

Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines

Measure Type
  • Process
Specifications
Specialty
  • Obstetrics/Gynecology
  • Urology
ID:

429
NQF:
eMeasure ID:
High Priority:

Yes

#429: Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy

Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse

Measure Type
  • Process
Specifications
Specialty
  • Obstetrics/Gynecology
  • Urology
ID:

430
NQF:
eMeasure ID:
High Priority:

Yes

#430: Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy

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 antiemetic agents of different classes preoperatively or intraoperatively

Measure Type
  • Process
Specifications
Specialty
  • Anesthesiology
ID:

431
NQF:

2152
eMeasure ID:
High Priority:

No

#431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

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 24 months AND who received brief counseling if identified as an unhealthy alcohol user

Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Gastroenterology
  • General Oncology
  • Internal Medicine
  • Mental/Behavioral Health
  • Neurology
  • Obstetrics/Gynecology
  • Otolaryngology
  • Physical Medicine
  • Preventive Medicine
  • Urology
ID:

432
NQF:
eMeasure ID:
High Priority:

Yes

#432: Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair

Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery

Measure Type
  • Outcome
Specifications
Specialty
  • Obstetrics/Gynecology
  • Urology
ID:

433
NQF:
eMeasure ID:
High Priority:

Yes

#433: Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

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 1 month after surgery

Measure Type
  • Outcome
Specifications
Specialty
  • Obstetrics/Gynecology
  • Urology
ID:

434
NQF:
eMeasure ID:
High Priority:

Yes

#434: Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair

Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery

Measure Type
  • Outcome
Specifications
Specialty
  • Obstetrics/Gynecology
  • Urology
ID:

435
NQF:
eMeasure ID:
High Priority:

Yes

#435: Quality of Life Assessment For Patients With Primary Headache Disorders

Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved

Measure Type
  • Outcome
Specifications
Specialty
  • Neurology
ID:

436
NQF:
eMeasure ID:
High Priority:

No

#436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: 

  • Automated exposure control
  • Adjustment of the mA and/or kV according to patient size
  • Use of iterative reconstruction technique
Measure Type
  • Process
Specifications
Specialty
  • Diagnostic Radiology
ID:

437
NQF:
eMeasure ID:
High Priority:

Yes

#437: Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure

Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure

Measure Type
  • Outcome
Specifications
Specialty
  • Interventional Radiology
ID:

438
NQF:
eMeasure ID:

CMS347v1
High Priority:

No

#438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Percentage of the following patients-all considered at high risk of cardiovascular events-who were prescribed or were on statin therapy during the measurement period: 

  • Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
  • Adults aged >=21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
  • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
Measure Type
  • Process
Specifications
Specialty
  • Cardiology
  • Family Medicine
  • Internal Medicine
  • Preventive Medicine
ID:

439
NQF:
eMeasure ID:
High Priority:

Yes

#439: Age Appropriate Screening Colonoscopy

The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31

Measure Type
  • Efficiency
Specifications
Specialty
  • Gastroenterology
ID:

440
NQF:
eMeasure ID:
High Priority:

Yes

#440: Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician

Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (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

Measure Type
  • Process
Specifications
Specialty
  • Dermatology
ID:

441
NQF:
eMeasure ID:
High Priority:

Yes

#441: Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)

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 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

     

    Measure Type
    • Intermediate Outcome
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    • Thoracic Surgery
    • Vascular Surgery
    ID:

    442
    NQF:

    0071
    eMeasure ID:
    High Priority:

    No

    #442: Persistence of Beta-Blocker Treatment After a Heart Attack

    The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Internal Medicine
    ID:

    443
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #443: Non-Recommended Cervical Cancer Screening in Adolescent Females

    The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    ID:

    444
    NQF:

    1799
    eMeasure ID:
    High Priority:

    Yes

    #444: Medication Management for People with Asthma

    The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Pediatrics
    ID:

    445
    NQF:

    0119
    eMeasure ID:
    High Priority:

    Yes

    #445: Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

    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

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Thoracic Surgery
    ID:

    446
    NQF:

    0733
    eMeasure ID:
    High Priority:

    Yes

    #446: Operative Mortality Stratified by the Five STS-EACTS Mortality Categories

    Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

    Measure Type
    • Outcome
    Specifications
    Specialty
    • N/A
    ID:

    447
    NQF:
    eMeasure ID:
    High Priority:

    No

    #447: Chlamydia Screening and Follow Up

    The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Pediatrics
    ID:

    448
    NQF:

    0567
    eMeasure ID:
    High Priority:

    Yes

    #448: Appropriate Workup Prior to Endometrial Ablation

    Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation

    Measure Type
    • Process
    Specifications
    Specialty
    • Obstetrics/Gynecology
    ID:

    449
    NQF:

    1857
    eMeasure ID:
    High Priority:

    Yes

    #449: HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies

    Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    ID:

    450
    NQF:

    1858
    eMeasure ID:
    High Priority:

    Yes

    #450: Trastuzumab Received By Patients With AJCC Stage I (T1c)–III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy

    Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    ID:

    451
    NQF:

    1859
    eMeasure ID:
    High Priority:

    No

    #451: KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    ID:

    452
    NQF:

    1860
    eMeasure ID:
    High Priority:

    Yes

    #452: Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    ID:

    453
    NQF:

    0210
    eMeasure ID:
    High Priority:

    Yes

    #453: Proportion Receiving Chemotherapy in the Last 14 Days of Life

    Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    ID:

    454
    NQF:

    0211
    eMeasure ID:
    High Priority:

    Yes

    #454: Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life

    Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Oncology
    ID:

    455
    NQF:

    0213
    eMeasure ID:
    High Priority:

    Yes

    #455: Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life

    Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Oncology
    ID:

    456
    NQF:

    0215
    eMeasure ID:
    High Priority:

    Yes

    #456: Proportion Not Admitted To Hospice

    Proportion of patients who died from cancer not admitted to hospice

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    ID:

    457
    NQF:

    0216
    eMeasure ID:
    High Priority:

    Yes

    #457: Proportion Admitted to Hospice for less than 3 days

    Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there

    Measure Type
    • Outcome
    Specifications
    Specialty
    • General Oncology
    ID:

    459
    NQF:
    eMeasure ID:
    High Priority:

    No

    #459: Average Change in Back Pain following Lumbar Discectomy / Laminotomy

    The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    460
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #460: Average Change in Back Pain following Lumbar Fusion

    The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had a lumbar spine fusion procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    461
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #461: Average Change in Leg Pain following Lumbar Discectomy / Laminotomy

    The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    462
    NQF:
    eMeasure ID:

    CMS645v1
    High Priority:

    No

    #462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • General Oncology
    • Urology
    ID:

    463
    NQF:
    eMeasure ID:
    High Priority:

    No

    #463: Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • Anesthesiology
    ID:

    464
    NQF:

    0657
    eMeasure ID:
    High Priority:

    Yes

    #464: Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use

    Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Infectious Disease
    • Otolaryngology
    • Pediatrics
    ID:

    465
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #465: Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

    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

    Measure Type
    • Process
    Specifications
    Specialty
    • Interventional Radiology
    ID:

    467
    NQF:

    1448
    eMeasure ID:
    High Priority:

    No

    #467: Developmental Screening in the First Three Years of Life

    The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months preceding or on their first, second or third birthday

    Measure Type
    • Process
    Specifications
    Specialty
    • Pediatrics

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