2018 MIPS Quality Benchmarks

What Are Quality Measure Benchmarks?

When a clinician or group submits measures for the Merit-based Incentive Payment System (MIPS) quality performance category, each measure is assessed against its benchmark to determine how many points the measure earns. In program year 2018, a clinician or group can receive anywhere from 3 to 10 points for each MIPS measure (not including any bonus points) that meets the data completeness standards and case minimum requirements through Benchmarks. Benchmarks are specific to the type of submission mechanism: Qualified Clinical Data Registries (QCDRs), Qualified Registries, Electronic Health Records (EHRs), CMS Web Interface, CMS-approved survey vendor (for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys), and Claims. In order to measure performance that is comparable across the spectrum of performance, benchmarks are established using historical data. Benchmarks (either historical or performance period benchmarks) are based on actual performance data from 2016 that was submitted to the Physician Quality Reporting System (PQRS) in 2017. The CMS Web Interface uses benchmarks from the Medicare Shared Savings Program.

How Are Benchmarks Displayed?

Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see table below). Clinicians who receive a score in the first or second decile will receive 3 points. Clinicians who are in the 3rd decile will receive somewhere between 3 and 3.9 points depending on their exact position in the decile, and clinicians in higher deciles will receive a corresponding number of points. For example, if a clinician submits performance data of 83% on a non-inverse measure, and the 5th decile begins at 72% and the 6th decile begins at 85%, then the clinician will receive between 5 and 5.9 points because 83% is in the 5th decile. For inverse measures where a higher performance is seen by a lower number on the performance score, the scores are reversed in the benchmark deciles.

Historical Benchmark Inclusion Criteria

Benchmarks are established using historical data, if available, which is the performance data submitted (during applicable submission period) by individuals and groups two years prior the start of the applicable performance year for which historical benchmarks are established.

What If A Quality Measure Does Not Have A Historical Benchmark?

For measures with no historical benchmark, MIPS will attempt to calculate benchmarks based on 2018 performance data. The same MIPS eligibility criteria listed above will be applied prior to establishing performance period benchmarks for measures. If no historical benchmark exists and no benchmark can be calculated, then the measure will receive 3 points as long as data completeness has been met. In the list of measure benchmarks, measures without historical benchmarks have no data provide in the decile fields.

Benchmarks for Multi-Strata Measures

Some measures have more than one numerator and denominator, or stratum, used to calculate overall performance. These multi-strata measures usually employ the average or weighted average of each numerator and denominator combination (i.e. the stratums are combined). However, in some measures there are specified stratum identified as the primary stratum for a performance rate to use in calculating benchmarks. The list of multi-strata measures and performance processes are provided here.

Measure NameMeasure IDSubmission MethodDecile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1Claims33.33 - 23.5423.53 - 18.2518.24 - 14.3014.29 - 11.5511.54 - 8.908.89 - 6.266.25 - 3.34<= 3.33
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1EHR83.10 - 67.9667.95 - 54.0954.08 - 43.2243.21 - 34.1234.11 - 27.2827.27 - 21.7521.74 - 15.74<= 15.73
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1Registry/QCDR57.89 - 42.3742.36 - 31.5931.58 - 25.7825.77 - 20.9420.93 - 16.8216.81 - 12.7812.77 - 7.70<= 7.69
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)5EHR43.53 - 53.2653.27 - 62.8562.86 - 68.7468.75 - 72.4072.41 - 77.9177.92 - 85.1885.19 - 91.33>= 91.34
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)5Registry/QCDR79.25 - 82.9282.93 - 85.5285.53 - 88.8888.89 - 91.6691.67 - 94.4394.44 - 96.7696.77 - 99.99100.00
Coronary Artery Disease (CAD): Antiplatelet Therapy6Registry/QCDR81.22 - 84.9484.95 - 87.4987.50 - 89.5689.57 - 91.6191.62 - 93.3493.35 - 95.8095.81 - 99.99100.00
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)7EHR51.35 - 68.2268.23 - 78.7778.78 - 82.6482.65 - 86.3286.33 - 90.7990.80 - 94.2594.26 - 97.60>= 97.61
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)7Registry/QCDR72.55 - 79.0679.07 - 84.4384.44 - 88.5188.52 - 91.1791.18 - 94.2894.29 - 98.0398.04 - 99.99100.00
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)8EHR60.00 - 65.7865.79 - 70.5870.59 - 74.9975.00 - 79.9980.00 - 85.9585.96 - 90.4790.48 - 95.99>= 96.00
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)8Registry/QCDR83.83 - 87.4987.50 - 90.6290.63 - 93.0993.10 - 95.4495.45 - 97.1397.14 - 99.99--100.00
Anti-Depressant Medication Management9EHR54.90 - 69.8969.90 - 80.3580.36 - 85.8685.87 - 88.5688.57 - 90.7190.72 - 92.9692.97 - 96.53>= 96.54
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation12Claims98.99 - 99.99------------100.00
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation12EHR82.75 - 87.4087.41 - 90.7690.77 - 93.6293.63 - 96.1696.17 - 97.8797.88 - 98.9698.97 - 99.99100.00
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation12Registry/QCDR94.70 - 98.1498.15 - 99.1699.17 - 99.99--------100.00
Age-Related Macular Degeneration (AMD): Dilated Macular Examination14Claims99.60 - 99.99------------100.00
Age-Related Macular Degeneration (AMD): Dilated Macular Examination14Registry/QCDR64.21 - 81.8181.82 - 90.8590.86 - 95.6995.70 - 98.6498.65 - 99.99----100.00
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy18EHR57.14 - 65.8365.84 - 72.7272.73 - 78.2178.22 - 83.1283.13 - 88.1788.18 - 92.3092.31 - 96.32>= 96.33
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care19Claims--------------100.00
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care19EHR46.15 - 56.8556.86 - 65.1365.14 - 72.3872.39 - 78.2178.22 - 84.2784.28 - 89.9389.94 - 95.41>= 95.42
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care19Registry/QCDR52.00 - 72.4072.41 - 81.4781.48 - 90.7690.77 - 96.5496.55 - 99.99----100.00
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin21Claims99.13 - 99.99------------100.00
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin21Registry/QCDR98.09 - 99.99------------100.00
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)23Claims--------------100.00
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)23Registry/QCDR95.49 - 99.7299.73 - 99.99----------100.00
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older24Claims78.43 - 90.9090.91 - 94.2894.29 - 96.2996.30 - 97.6697.67 - 99.99----100.00
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older24Registry/QCDR9.29 - 18.5718.58 - 28.5628.57 - 36.0536.06 - 60.9260.93 - 86.6686.67 - 99.99--100.00
Screening for Osteoporosis for Women Aged 65-85 Years of Age39Claims29.30 - 38.4538.46 - 45.6045.61 - 52.3352.34 - 60.3960.40 - 69.9469.95 - 81.5781.58 - 95.67>= 95.68
Screening for Osteoporosis for Women Aged 65-85 Years of Age39Registry/QCDR13.36 - 29.0529.06 - 47.0147.02 - 55.9255.93 - 65.4165.42 - 73.0773.08 - 82.5082.51 - 92.30>= 92.31
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery43Registry/QCDR98.51 - 99.1499.15 - 99.99----------100.00
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery44Registry/QCDR94.44 - 96.1196.12 - 97.2397.24 - 98.7298.73 - 99.99------100.00
Medication Reconciliation Post-Discharge46Claims96.15 - 98.5098.51 - 99.99----------100.00
Medication Reconciliation Post-Discharge46Registry/QCDR96.15 - 99.4399.44 - 99.99----------100.00
Care Plan47Claims18.63 - 36.2636.27 - 68.1468.15 - 93.7293.73 - 98.7398.74 - 99.99----100.00
Care Plan47Registry/QCDR44.99 - 66.1666.17 - 77.6977.70 - 86.5886.59 - 93.7493.75 - 97.6997.70 - 99.5999.60 - 99.99100.00
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older48Claims9.49 - 37.9237.93 - 81.6481.65 - 98.0498.05 - 99.99------100.00
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older48Registry/QCDR41.23 - 59.0559.06 - 71.6971.70 - 81.4781.48 - 89.3289.33 - 95.8295.83 - 99.3199.32 - 99.99100.00
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older50Claims85.00 - 94.7394.74 - 98.5298.53 - 99.99--------100.00
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older50Registry/QCDR87.50 - 93.5493.55 - 97.4397.44 - 99.99--------100.00
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation51Claims21.74 - 52.3752.38 - 81.8181.82 - 95.8295.83 - 99.99------100.00
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation51Registry/QCDR69.23 - 77.0077.01 - 82.9782.98 - 87.9487.95 - 93.3293.33 - 95.6995.70 - 98.3698.37 - 99.99100.00
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy52Claims99.03 - 99.99------------100.00
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy52Registry/QCDR84.21 - 93.9793.98 - 96.1496.15 - 97.8197.82 - 99.99------100.00
Appropriate Treatment for Children with Upper Respiratory Infection (URI)65EHR74.00 - 82.4282.43 - 87.9087.91 - 91.2991.30 - 93.9994.00 - 95.9996.00 - 98.9298.93 - 99.99100.00
Appropriate Treatment for Children with Upper Respiratory Infection (URI)65Registry/QCDR74.19 - 89.1889.19 - 93.5493.55 - 99.99--------100.00
Appropriate Testing for Children with Pharyngitis66EHR43.33 - 56.1856.19 - 66.6666.67 - 74.7474.75 - 80.5180.52 - 84.4384.44 - 87.2987.30 - 91.88>= 91.89
Appropriate Testing for Children with Pharyngitis66Registry/QCDR----------------
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow67Registry/QCDR--------------100.00
Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy68Registry/QCDR----------------
Hematology: Multiple Myeloma: Treatment with Bisphosphonates69Registry/QCDR--------------100.00
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry70Registry/QCDR97.14 - 99.99------------100.00
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections76Claims85.37 - 95.2395.24 - 98.0498.05 - 99.99--------100.00
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections76Registry/QCDR91.85 - 96.1496.15 - 98.8898.89 - 99.99--------100.00
Acute Otitis Externa (AOE): Topical Therapy91Claims61.54 - 72.7272.73 - 86.3586.36 - 95.8295.83 - 98.3898.39 - 99.99----100.00
Acute Otitis Externa (AOE): Topical Therapy91Registry/QCDR59.26 - 69.9970.00 - 74.9975.00 - 80.8380.84 - 86.2086.21 - 92.3092.31 - 95.4495.45 - 99.99100.00
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use93Claims88.37 - 95.9996.00 - 97.4997.50 - 99.99--------100.00
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use93Registry/QCDR82.80 - 90.4790.48 - 94.4394.44 - 97.6197.62 - 99.99------100.00
Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade99Claims--------------100.00
Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade99Registry/QCDR99.39 - 99.99------------100.00
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade100Claims--------------100.00
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade100Registry/QCDR--------------100.00
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients102EHR----------------
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients102Registry/QCDR98.92 - 99.99------------100.00
Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer104Registry/QCDR84.85 - 94.1194.12 - 95.8795.88 - 99.99--------100.00
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment107EHR22.86 - 51.9952.00 - 74.4274.43 - 84.9284.93 - 88.4588.46 - 92.8092.81 - 95.5095.51 - 96.47>= 96.48
Osteoarthritis (OA): Function and Pain Assessment109Claims89.34 - 96.8796.88 - 98.7398.74 - 99.7199.72 - 99.99------100.00
Osteoarthritis (OA): Function and Pain Assessment109Registry/QCDR15.38 - 35.3235.33 - 64.9965.00 - 84.8984.90 - 95.1895.19 - 99.99----100.00
Preventive Care and Screening: Influenza Immunization110Claims23.29 - 33.1333.14 - 46.9346.94 - 62.6262.63 - 74.3574.36 - 86.0586.06 - 97.3497.35 - 99.99100.00
Preventive Care and Screening: Influenza Immunization110EHR14.55 - 21.8321.84 - 29.0029.01 - 35.9936.00 - 43.5343.54 - 52.1352.14 - 63.1263.13 - 78.42>= 78.43
Preventive Care and Screening: Influenza Immunization110Registry/QCDR26.89 - 40.4840.49 - 49.9950.00 - 57.0657.07 - 64.7864.79 - 73.0773.08 - 82.7082.71 - 96.43>= 96.44
Pneumococcal Vaccination Status for Older Adults111Claims44.78 - 55.8755.88 - 65.5765.58 - 73.2773.28 - 80.6780.68 - 87.3487.35 - 93.8493.85 - 99.68>= 99.69
Pneumococcal Vaccination Status for Older Adults111EHR15.40 - 25.6125.62 - 37.3037.31 - 47.4847.49 - 56.4656.47 - 65.5265.53 - 75.0875.09 - 85.70>= 85.71
Pneumococcal Vaccination Status for Older Adults111Registry/QCDR29.93 - 45.2745.28 - 55.0955.10 - 62.5862.59 - 69.9970.00 - 76.9676.97 - 83.9984.00 - 92.88>= 92.89
Breast Cancer Screening112Claims33.68 - 45.3545.36 - 53.2153.22 - 60.2860.29 - 67.8367.84 - 76.5576.56 - 89.2389.24 - 99.99100.00
Breast Cancer Screening112EHR19.19 - 31.9731.98 - 40.5840.59 - 48.4048.41 - 55.7355.74 - 63.1263.13 - 70.0570.06 - 78.94>= 78.95
Breast Cancer Screening112Registry/QCDR38.69 - 52.5352.54 - 60.1360.14 - 65.1865.19 - 70.1770.18 - 76.0176.02 - 82.7282.73 - 92.04>= 92.05
Colorectal Cancer Screening113Claims32.69 - 43.6843.69 - 55.1555.16 - 66.0966.10 - 77.3677.37 - 86.6386.64 - 94.5194.52 - 99.99100.00
Colorectal Cancer Screening113EHR12.61 - 23.9123.92 - 34.3134.32 - 44.5444.55 - 54.0954.10 - 63.6363.64 - 73.0973.10 - 83.14>= 83.15
Colorectal Cancer Screening113Registry/QCDR37.55 - 53.0053.01 - 59.9159.92 - 66.2066.21 - 73.0773.08 - 79.4879.49 - 86.4286.43 - 93.81>= 93.82
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis116Registry/QCDR23.90 - 30.8730.88 - 38.7738.78 - 58.8058.81 - 99.99------100.00
Diabetes: Eye Exam117Claims88.98 - 98.4498.45 - 99.99----------100.00
Diabetes: Eye Exam117EHR84.83 - 92.8592.86 - 95.3295.33 - 96.9696.97 - 98.1998.20 - 99.1799.18 - 99.8299.83 - 99.99100.00
Diabetes: Eye Exam117Registry/QCDR80.91 - 92.8592.86 - 96.5396.54 - 98.7098.71 - 99.99------100.00
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)118Registry/QCDR74.37 - 77.0377.04 - 79.8479.85 - 82.2982.30 - 84.9084.91 - 87.3187.32 - 89.9990.00 - 95.44>= 95.45
Diabetes: Medical Attention for Nephropathy119EHR64.29 - 70.2070.21 - 75.2775.28 - 79.6879.69 - 83.4983.50 - 87.3687.37 - 91.1791.18 - 94.99>= 95.00
Diabetes: Medical Attention for Nephropathy119Registry/QCDR72.00 - 76.5876.59 - 80.8480.85 - 84.0284.03 - 86.9186.92 - 90.0990.10 - 93.2393.24 - 97.66>= 97.67
Adult Kidney Disease: Blood Pressure Management122Registry/QCDR69.20 - 79.1679.17 - 90.6990.70 - 95.0895.09 - 96.4796.48 - 97.6697.67 - 98.7398.74 - 99.99100.00
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation126Registry/QCDR16.47 - 37.6337.64 - 54.5454.55 - 66.9866.99 - 77.2677.27 - 85.1085.11 - 94.5594.56 - 99.99100.00
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear127Registry/QCDR11.75 - 28.1128.12 - 45.2745.28 - 61.5161.52 - 72.1572.16 - 82.7782.78 - 94.2894.29 - 99.99100.00
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan128Claims43.20 - 48.4248.43 - 58.9258.93 - 83.5683.57 - 96.6096.61 - 99.5399.54 - 99.99--100.00
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan128EHR28.22 - 31.9231.93 - 35.3435.35 - 38.7638.77 - 42.8842.89 - 49.1849.19 - 64.8364.84 - 85.93>= 85.94
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan128Registry/QCDR45.12 - 52.0552.06 - 59.9960.00 - 68.7468.75 - 77.7777.78 - 86.0786.08 - 92.8592.86 - 99.42>= 99.43
Documentation of Current Medications in the Medical Record130Claims97.20 - 99.2399.24 - 99.7999.80 - 99.99--------100.00
Documentation of Current Medications in the Medical Record130EHR86.25 - 91.9191.92 - 94.8594.86 - 96.6996.70 - 97.9897.99 - 98.8798.88 - 99.5499.55 - 99.95>= 99.96
Documentation of Current Medications in the Medical Record130Registry/QCDR77.08 - 90.2290.23 - 95.9795.98 - 98.6098.61 - 99.6999.70 - 99.99----100.00
Pain Assessment and Follow-Up131Claims79.10 - 96.3696.37 - 99.3799.38 - 99.9199.92 - 99.99------100.00
Pain Assessment and Follow-Up131Registry/QCDR20.00 - 49.7949.80 - 77.6677.67 - 88.4988.50 - 95.5395.54 - 99.3399.34 - 99.99--100.00
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan134Claims17.13 - 29.2729.28 - 65.0065.01 - 91.4691.47 - 99.3499.35 - 99.99----100.00
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan134EHR0.51 - 1.291.30 - 5.095.10 - 12.5112.52 - 25.6025.61 - 42.3042.31 - 64.3664.37 - 83.73>= 83.74
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan134Registry/QCDR28.44 - 53.2453.25 - 62.8162.82 - 71.1571.16 - 79.9079.91 - 88.6988.70 - 96.4296.43 - 99.99100.00
Melanoma: Continuity of Care - Recall System137Registry/QCDR87.50 - 93.6493.65 - 96.9696.97 - 99.99--------100.00
Melanoma: Coordination of Care138Registry/QCDR52.38 - 78.9778.98 - 88.8888.89 - 95.5495.55 - 99.99------100.00
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement140Claims97.33 - 99.99------------100.00
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement140Registry/QCDR35.90 - 57.8857.89 - 71.7571.76 - 86.3886.39 - 94.2294.23 - 98.3198.32 - 99.99--100.00
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care141Claims--------------100.00
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care141Registry/QCDR69.40 - 86.9686.97 - 95.0495.05 - 97.9597.96 - 99.6499.65 - 99.99----100.00
Oncology: Medical and Radiation - Pain Intensity Quantified143EHR82.07 - 91.9091.91 - 96.5496.55 - 99.0799.08 - 99.8699.87 - 99.99----100.00
Oncology: Medical and Radiation - Pain Intensity Quantified143Registry/QCDR82.03 - 90.7690.77 - 95.3995.40 - 97.5697.57 - 99.0999.10 - 99.99----100.00
Oncology: Medical and Radiation - Plan of Care for Pain144Registry/QCDR91.74 - 97.1397.14 - 98.6098.61 - 99.99--------100.00
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy145Claims47.89 - 63.8863.89 - 74.9074.91 - 82.3482.35 - 87.9988.00 - 92.5892.59 - 96.5496.55 - 99.99100.00
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy145Registry/QCDR71.91 - 81.2481.25 - 87.0987.10 - 91.6691.67 - 95.6895.69 - 98.6798.68 - 99.99--100.00
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms146Claims0.23 - 0.01------------0.00
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms146Registry/QCDR0.31 - 0.050.04 - 0.01----------0.00
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy147Claims66.67 - 79.1679.17 - 87.4987.50 - 93.2393.24 - 96.5496.55 - 99.99----100.00
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy147Registry/QCDR83.67 - 90.7190.72 - 95.4195.42 - 97.8297.83 - 99.99------100.00
Falls: Risk Assessment154Claims96.84 - 99.99------------100.00
Falls: Risk Assessment154Registry/QCDR49.22 - 72.8372.84 - 84.6184.62 - 95.2395.24 - 99.8899.89 - 99.99----100.00
Falls: Plan of Care155Claims42.25 - 61.3261.33 - 87.6487.65 - 98.8998.90 - 99.99------100.00
Falls: Plan of Care155Registry/QCDR46.15 - 75.1275.13 - 89.1889.19 - 94.1694.17 - 97.3297.33 - 99.99----100.00
Oncology: Radiation Dose Limits to Normal Tissues156Claims----------------
Oncology: Radiation Dose Limits to Normal Tissues156Registry/QCDR95.87 - 98.9498.95 - 99.99----------100.00
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis160EHR----------------
Diabetes: Foot Exam163EHR9.38 - 16.3216.33 - 24.0124.02 - 31.5731.58 - 44.6544.66 - 59.0859.09 - 69.4369.44 - 79.71>= 79.72
Coronary Artery Bypass Graft (CABG): Prolonged Intubation164Registry/QCDR12.39 - 9.879.86 - 8.748.73 - 6.806.79 - 5.355.34 - 4.234.22 - 3.043.03 - 1.35<= 1.34
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate165Registry/QCDR0.54 - 0.01------------0.00
Coronary Artery Bypass Graft (CABG): Stroke166Registry/QCDR2.53 - 1.861.85 - 1.361.35 - 0.880.87 - 0.01------0.00
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure167Registry/QCDR3.74 - 2.792.78 - 2.182.17 - 1.681.67 - 1.191.18 - 0.01----0.00
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration168Registry/QCDR3.85 - 3.293.28 - 2.682.67 - 2.062.05 - 1.501.49 - 0.950.94 - 0.01--0.00
Rheumatoid Arthritis (RA): Tuberculosis Screening176Registry/QCDR----------------
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity177Registry/QCDR----------------
Rheumatoid Arthritis (RA): Functional Status Assessment178Registry/QCDR48.99 - 68.7068.71 - 81.0781.08 - 92.7792.78 - 96.0396.04 - 99.5999.60 - 99.99--100.00
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis179Registry/QCDR----------------
Rheumatoid Arthritis (RA): Glucocorticoid Management180Registry/QCDR----------------
Elder Maltreatment Screen and Follow-Up Plan181Claims82.12 - 99.6099.61 - 99.99----------100.00
Elder Maltreatment Screen and Follow-Up Plan181Registry/QCDR51.20 - 75.5375.54 - 83.7583.76 - 90.2890.29 - 95.7095.71 - 98.9798.98 - 99.99--100.00
Functional Outcome Assessment182Claims99.95 - 99.99------------100.00
Functional Outcome Assessment182Registry/QCDR94.95 - 97.2097.21 - 99.7799.78 - 99.99--------100.00
Colonoscopy Interval for Patients with a History of Adenomatous Polyps.- Avoidance of Inappropriate Use185Claims98.00 - 99.99------------100.00
Colonoscopy Interval for Patients with a History of Adenomatous Polyps.- Avoidance of Inappropriate Use185Registry/QCDR90.91 - 95.9996.00 - 97.4997.50 - 99.6499.65 - 99.99------100.00
Stroke and Stroke Rehabilitation: Thrombolytic Therapy187Registry/QCDR52.63 - 57.4757.48 - 63.8863.89 - 71.0071.01 - 80.5580.56 - 96.5296.53 - 99.99--100.00
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery191EHR83.33 - 88.8288.83 - 91.8191.82 - 94.1194.12 - 95.6995.70 - 96.8896.89 - 97.9897.99 - 99.31>= 99.32
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery191Registry/QCDR75.68 - 84.9184.92 - 91.1091.11 - 94.3594.36 - 96.4696.47 - 97.7997.80 - 99.99--100.00
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures192EHR0.33 - 0.01------------0.00
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures192Registry/QCDR0.50 - 0.180.17 - 0.01----------0.00
Radiology: Stenosis Measurement in Carotid Imaging Reports195Claims85.94 - 92.5892.59 - 95.9195.92 - 97.9998.00 - 99.4699.47 - 99.99----100.00
Radiology: Stenosis Measurement in Carotid Imaging Reports195Registry/QCDR91.92 - 96.0496.05 - 98.2798.28 - 99.99--------100.00
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet204Claims83.87 - 86.9086.91 - 89.0089.01 - 90.9090.91 - 92.6592.66 - 94.5894.59 - 97.0197.02 - 99.99100.00
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet204EHR53.33 - 61.7561.76 - 68.3268.33 - 73.2373.24 - 77.1077.11 - 80.6080.61 - 83.9183.92 - 87.92>= 87.93
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet204Registry/QCDR76.89 - 81.7081.71 - 84.6184.62 - 87.1687.17 - 89.5189.52 - 91.8791.88 - 94.8994.90 - 99.99100.00
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis205Registry/QCDR----------------
Functional Status Change for Patients with Knee Impairments217Registry/QCDR----------------
Functional Status Change for Patients with Hip Impairments218Registry/QCDR----------------
Functional Status Change for Patients with Foot or Ankle Impairments219Registry/QCDR----------------
Functional Status Change for Patients with Lumbar Impairments220Registry/QCDR----------------
Functional Status Change for Patients with Shoulder Impairments221Registry/QCDR----------------
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments222Registry/QCDR----------------
Functional Status Change for Patients with General Orthopaedic Impairments223Registry/QCDR----------------
Melanoma: Overutilization of Imaging Studies in Melanoma224Registry/QCDR--------------100.00
Radiology: Reminder System for Screening Mammograms225Claims94.20 - 98.2298.23 - 99.6799.68 - 99.99--------100.00
Radiology: Reminder System for Screening Mammograms225Registry/QCDR--------------100.00
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention226Claims96.65 - 98.5998.60 - 99.6199.62 - 99.99--------100.00
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention226EHR72.72 - 82.4082.41 - 87.5587.56 - 90.5090.51 - 92.7492.75 - 94.6394.64 - 96.5296.53 - 98.51>= 98.52
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention226Registry/QCDR83.72 - 88.3888.39 - 91.1091.11 - 93.3493.35 - 95.4495.45 - 97.3597.36 - 99.0099.01 - 99.99100.00
Controlling High Blood Pressure236Claims58.02 - 63.9063.91 - 68.3668.37 - 72.9172.92 - 76.9176.92 - 81.6581.66 - 86.9586.96 - 94.06>= 94.07
Controlling High Blood Pressure236EHR51.10 - 56.5156.52 - 60.7760.78 - 64.2864.29 - 67.4667.47 - 70.9370.94 - 74.8874.89 - 80.42>= 80.43
Controlling High Blood Pressure236Registry/QCDR56.36 - 62.9162.92 - 67.5367.54 - 70.6870.69 - 73.7873.79 - 77.4577.46 - 82.1282.13 - 88.58>= 88.59
Use of High-Risk Medications in the Elderly238EHR12.02 - 6.846.83 - 3.533.52 - 1.501.49 - 0.490.48 - 0.01----0.00
Use of High-Risk Medications in the Elderly238Registry/QCDR11.54 - 7.337.32 - 4.114.10 - 1.941.93 - 0.770.76 - 0.240.23 - 0.01--0.00
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents239EHR21.69 - 26.0926.10 - 28.8628.87 - 30.4730.48 - 31.7631.77 - 32.6532.66 - 33.3233.33 - 40.77>= 40.78
Childhood Immunization Status240EHR4.35 - 8.848.85 - 11.9511.96 - 16.1616.17 - 23.8023.81 - 31.2531.26 - 38.7938.80 - 50.87>= 50.88
Cardiac Rehabilitation Patient Referral from an Outpatient Setting243Registry/QCDR----------------
Barrett's Esophagus249Claims--------------100.00
Barrett's Esophagus249Registry/QCDR--------------100.00
Radical Prostatectomy Pathology Reporting250Claims----------------
Radical Prostatectomy Pathology Reporting250Registry/QCDR97.28 - 99.99------------100.00
Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients251Claims--------------100.00
Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients251Registry/QCDR--------------100.00
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain254Claims----------------
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain254Registry/QCDR99.51 - 99.99------------100.00
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure255Claims----------------
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure255Registry/QCDR----------------
Statin Therapy at Discharge after Lower Extremity Bypass (LEB)257Registry/QCDR----------------
Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)258Registry/QCDR----------------
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)259Registry/QCDR----------------
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)260Registry/QCDR----------------
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness261Claims----------------
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness261Registry/QCDR----------------
Image Confirmation of Successful Excision of Image-Localized Breast Lesion262Registry/QCDR--------------100.00
Preoperative Diagnosis of Breast Cancer263Registry/QCDR98.98 - 99.99------------100.00
Sentinel Lymph Node Biopsy for Invasive Breast Cancer264Registry/QCDR97.87 - 98.9898.99 - 99.99----------100.00
Biopsy Follow-Up265Registry/QCDR66.67 - 85.7085.71 - 92.5892.59 - 97.8097.81 - 99.99------100.00
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy268Claims----------------
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy268Registry/QCDR----------------
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment271Registry/QCDR----------------
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy275Registry/QCDR----------------
Sleep Apnea: Assessment of Sleep Symptoms276Registry/QCDR----------------
Sleep Apnea: Severity Assessment at Initial Diagnosis277Registry/QCDR----------------
Sleep Apnea: Positive Airway Pressure Therapy Prescribed278Registry/QCDR----------------
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy279Registry/QCDR----------------
Dementia: Cognitive Assessment281EHR33.33 - 52.7752.78 - 59.0859.09 - 69.4169.42 - 77.7777.78 - 86.8986.90 - 95.2395.24 - 99.99100.00
Dementia: Functional Status Assessment282Registry/QCDR----------------
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management .283Registry/QCDR----------------
Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia286Registry/QCDR----------------
Dementia: Caregiver Education and Support288Registry/QCDR----------------
Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease290Registry/QCDR75.76 - 80.7680.77 - 94.8694.87 - 95.4495.45 - 96.6696.67 - 99.0999.10 - 99.99--100.00
Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment291Registry/QCDR----------------
Parkinson's Disease: Rehabilitative Therapy Options293Registry/QCDR----------------
Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery303Registry/QCDR13.16 - 33.3233.33 - 51.9151.92 - 72.9672.97 - 82.7582.76 - 88.3288.33 - 92.5192.52 - 98.91>= 98.92
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery304Registry/QCDR7.69 - 29.9930.00 - 49.9950.00 - 68.7468.75 - 80.8480.85 - 86.2686.27 - 92.1692.17 - 99.99100.00
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment305EHR0.49 - 0.650.66 - 0.770.78 - 0.890.90 - 2.102.11 - 2.712.72 - 4.064.07 - 14.48>= 14.49
Cervical Cancer Screening309EHR8.82 - 14.5714.58 - 20.8820.89 - 28.2928.30 - 37.6437.65 - 47.7547.76 - 58.1558.16 - 71.63>= 71.64
Chlamydia Screening for Women310EHR13.89 - 19.9920.00 - 28.1228.13 - 32.8032.81 - 38.8338.84 - 48.1448.15 - 55.1755.18 - 63.99>= 64.00
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented317Claims49.53 - 57.7457.75 - 66.4566.46 - 78.5678.57 - 90.5290.53 - 98.1698.17 - 99.99--100.00
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented317EHR16.53 - 20.4020.41 - 23.9423.95 - 26.9326.94 - 29.9930.00 - 33.3233.33 - 37.6137.62 - 45.98>= 45.99
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented317Registry/QCDR35.65 - 51.1551.16 - 64.2164.22 - 71.2571.26 - 76.4676.47 - 81.4081.41 - 88.0688.07 - 97.68>= 97.69
Falls: Screening for Future Fall Risk318EHR9.14 - 20.1620.17 - 33.7033.71 - 48.3648.37 - 65.6765.68 - 81.7681.77 - 93.3993.40 - 98.80>= 98.81
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients320Claims91.51 - 96.4096.41 - 99.99----------100.00
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients320Registry/QCDR87.30 - 91.4891.49 - 94.2594.26 - 96.2196.22 - 98.6898.69 - 99.99----100.00
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients322Registry/QCDR3.45 - 0.930.92 - 0.01----------0.00
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)323Registry/QCDR0.92 - 0.01------------0.00
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients324Registry/QCDR17.89 - 2.362.35 - 0.01----------0.00
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions325Registry/QCDR66.67 - 82.9582.96 - 91.5291.53 - 98.0498.05 - 99.99------100.00
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy326Claims93.91 - 97.2997.30 - 99.4099.41 - 99.99--------100.00
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy326Registry/QCDR74.17 - 78.2878.29 - 81.2481.25 - 83.9183.92 - 86.3786.38 - 89.2389.24 - 93.2293.23 - 99.99100.00
Pediatric Kidney Disease: Adequacy of Volume Management327Registry/QCDR----------------
Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL328Registry/QCDR----------------
Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis329Registry/QCDR----------------
Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days330Registry/QCDR----------------
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)331Registry/QCDR90.10 - 84.6384.62 - 80.5980.58 - 68.6768.66 - 45.1145.10 - 9.109.09 - 1.231.22 - 0.010.00
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)332Registry/QCDR31.58 - 48.2748.28 - 54.5454.55 - 61.0861.09 - 68.0868.09 - 83.8683.87 - 95.9996.00 - 99.99100.00
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)333Registry/QCDR3.57 - 1.891.88 - 0.01----------0.00
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)334Registry/QCDR3.13 - 1.401.39 - 0.400.39 - 0.01--------0.00
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)335Registry/QCDR----------------
Maternity Care: Post-Partum Follow-Up and Care Coordination336Registry/QCDR----------------
Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier337Registry/QCDR54.21 - 79.2479.25 - 87.2387.24 - 91.7591.76 - 95.4095.41 - 96.7496.75 - 99.99--100.00
HIV Viral Load Suppression338Registry/QCDR----------------
HIV Medical Visit Frequency340Registry/QCDR----------------
Pain Brought Under Control Within 48 Hours342Registry/QCDR93.22 - 99.99------------100.00
Screening Colonoscopy Adenoma Detection Rate343Registry/QCDR34.48 - 38.7338.74 - 43.8943.90 - 48.5648.57 - 53.1853.19 - 59.4059.41 - 67.6467.65 - 83.99>= 84.00
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)344Registry/QCDR----------------
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)345Registry/QCDR----------------
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA)346Registry/QCDR----------------
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital347Registry/QCDR----------------
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate348Registry/QCDR----------------
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy350Registry/QCDR----------------
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation351Registry/QCDR----------------
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet352Registry/QCDR----------------
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report353Registry/QCDR----------------
Anastomotic Leak Intervention354Registry/QCDR----------------
Unplanned Reoperation within the 30 Day Postoperative Period355Registry/QCDR----------------
Unplanned Hospital Readmission within 30 Days of Principal Procedure356Registry/QCDR----------------
Surgical Site Infection (SSI)357Registry/QCDR----------------
Patient-Centered Surgical Risk Assessment and Communication358Registry/QCDR31.03 - 67.9968.00 - 91.0591.06 - 97.1197.12 - 99.99------100.00
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description359Registry/QCDR----------------
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies360Registry/QCDR----------------
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry361Registry/QCDR----------------
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes362Registry/QCDR----------------
Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive363Registry/QCDR----------------
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines364Registry/QCDR----------------
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication366EHR----------------
Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use367EHR----------------
Pregnant women that had HBsAg testing369EHR----------------
Depression Remission at Twelve Months370EHR----------------
Depression Remission at Twelve Months370Registry/QCDR----------------
Depression Utilization of the PHQ-9 Tool371EHR1.65 - 2.452.46 - 3.323.33 - 4.324.33 - 5.595.60 - 8.328.33 - 14.9915.00 - 48.14>= 48.15
Maternal Depression Screening372EHR----------------
Hypertension: Improvement in Blood Pressure373EHR17.07 - 22.2122.22 - 27.2627.27 - 32.3232.33 - 37.8837.89 - 42.8542.86 - 48.4748.48 - 55.99>= 56.00
Closing the Referral Loop: Receipt of Specialist Report374EHR14.29 - 24.1324.14 - 33.5733.58 - 43.6543.66 - 54.3354.34 - 63.7863.79 - 74.9975.00 - 88.63>= 88.64
Closing the Referral Loop: Receipt of Specialist Report374Registry/QCDR65.22 - 99.99------------100.00
Functional Status Assessment for Total Knee Replacement375EHR5.08 - 14.8014.81 - 25.7625.77 - 36.5136.52 - 44.7344.74 - 51.2751.28 - 60.5560.56 - 79.99>= 80.00
Functional Status Assessment for Total Hip Replacement376EHR10.34 - 26.0826.09 - 41.6641.67 - 47.8247.83 - 56.5056.51 - 61.1561.16 - 64.9965.00 - 72.72>= 72.73
Functional Status Assessments for Congestive Heart Failure377EHR----------------
Children Who Have Dental Decay or Cavities378EHR--------------0.00
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists379EHR0.36 - 0.540.55 - 0.780.79 - 1.111.12 - 2.032.04 - 4.404.41 - 5.095.10 - 7.36>= 7.37
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment382EHR----------------
Adherence to Antipsychotic Medications For Individuals with Schizophrenia383Registry/QCDR68.57 - 77.7777.78 - 88.1988.20 - 93.9994.00 - 98.8598.86 - 99.99----100.00
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery384Registry/QCDR----------------
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery385Registry/QCDR----------------
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences386Registry/QCDR----------------
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users387Registry/QCDR----------------
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)388Registry/QCDR--------------0.00
Cataract Surgery: Difference Between Planned and Final Refraction389Registry/QCDR13.89 - 38.2338.24 - 58.4858.49 - 74.9975.00 - 82.9782.98 - 91.9091.91 - 96.2496.25 - 99.99100.00
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options390Registry/QCDR----------------
Follow-Up After Hospitalization for Mental Illness (FUH)391Registry/QCDR----------------
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation392Registry/QCDR----------------
HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision393Registry/QCDR----------------
Immunizations for Adolescents394Registry/QCDR----------------
Lung Cancer Reporting (Biopsy/Cytology Specimens)395Claims96.00 - 99.99------------100.00
Lung Cancer Reporting (Biopsy/Cytology Specimens)395Registry/QCDR95.83 - 96.6696.67 - 99.99----------100.00
Lung Cancer Reporting (Resection Specimens)396Claims----------------
Lung Cancer Reporting (Resection Specimens)396Registry/QCDR----------------
Melanoma Reporting397Claims95.00 - 97.0597.06 - 99.99----------100.00
Melanoma Reporting397Registry/QCDR97.14 - 99.99------------100.00
Optimal Asthma Control398Registry/QCDR----------------
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk400Registry/QCDR1.62 - 2.212.22 - 3.223.23 - 11.1011.11 - 19.6019.61 - 27.2127.22 - 35.3535.36 - 68.74>= 68.75
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis401Registry/QCDR----------------
Tobacco Use and Help with Quitting Among Adolescents402Registry/QCDR71.85 - 75.7575.76 - 85.7085.71 - 89.9990.00 - 92.5892.59 - 95.3795.38 - 97.5597.56 - 99.99100.00
Adult Kidney Disease: Referral to Hospice403Registry/QCDR----------------
Anesthesiology Smoking Abstinence404Registry/QCDR42.86 - 49.9950.00 - 61.6961.70 - 66.6666.67 - 73.9073.91 - 82.6082.61 - 91.7091.71 - 99.99100.00
Appropriate Follow-up Imaging for Incidental Abdominal Lesions405Claims33.33 - 22.0422.03 - 15.3915.38 - 11.1211.11 - 7.517.50 - 4.214.20 - 1.531.52 - 0.010.00
Appropriate Follow-up Imaging for Incidental Abdominal Lesions405Registry/QCDR25.00 - 18.1918.18 - 12.3912.38 - 8.718.70 - 5.095.08 - 2.232.22 - 0.01--0.00
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients406Claims45.45 - 36.0136.00 - 30.0130.00 - 21.6321.62 - 15.0115.00 - 8.718.70 - 4.184.17 - 0.010.00
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients406Registry/QCDR37.32 - 21.4421.43 - 15.6415.63 - 6.576.56 - 4.124.11 - 1.311.30 - 0.01--0.00
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia407Claims----------------
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia407Registry/QCDR----------------
Opioid Therapy Follow-up Evaluation408Registry/QCDR75.51 - 82.6682.67 - 92.0192.02 - 97.7897.79 - 99.99------100.00
Clinical Outcome Post Endovascular Stroke Treatment409Registry/QCDR----------------
Psoriasis: Clinical Response to Oral Systemic or Biologic Medications410Registry/QCDR40.91 - 54.5454.55 - 70.8270.83 - 80.3080.31 - 91.5091.51 - 95.6495.65 - 99.99--100.00
Depression Remission at Six Months411Registry/QCDR----------------
Documentation of Signed Opioid Treatment Agreement412Registry/QCDR37.14 - 70.3770.38 - 94.2894.29 - 99.0499.05 - 99.99------100.00
Door to Puncture Time for Endovascular Stroke Treatment413Registry/QCDR----------------
Evaluation or Interview for Risk of Opioid Misuse414Registry/QCDR79.89 - 95.3495.35 - 98.2398.24 - 99.99--------100.00
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older415Claims90.91 - 93.5493.55 - 95.4495.45 - 96.2996.30 - 99.99------100.00
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older415Registry/QCDR88.52 - 90.3590.36 - 91.7991.80 - 94.0994.10 - 95.4195.42 - 96.6696.67 - 97.8297.83 - 99.99100.00
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years416Claims----------------
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years416Registry/QCDR----------------
Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive417Registry/QCDR----------------
Osteoporosis Management in Women Who Had a Fracture418Claims----------------
Osteoporosis Management in Women Who Had a Fracture418Registry/QCDR4.29 - 4.995.00 - 7.167.17 - 10.3810.39 - 15.5715.58 - 18.1718.18 - 88.3288.33 - 99.99100.00
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination419Claims----------------
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination419Registry/QCDR98.23 - 99.2799.28 - 99.99----------100.00
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey420Registry/QCDR----------------
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal421Registry/QCDR----------------
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury422Claims----------------
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury422Registry/QCDR----------------
Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy423Claims----------------
Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy423Registry/QCDR----------------
Perioperative Temperature Management424Registry/QCDR99.63 - 99.99------------100.00
Photodocumentation of Cecal Intubation425Claims98.55 - 98.9798.98 - 99.5699.57 - 99.99--------100.00
Photodocumentation of Cecal Intubation425Registry/QCDR63.36 - 78.5278.53 - 98.5898.59 - 99.99--------100.00
Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)426Registry/QCDR99.78 - 99.99------------100.00
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)427Registry/QCDR--------------100.00
Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence428Registry/QCDR----------------
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy429Claims----------------
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy429Registry/QCDR----------------
Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy430Registry/QCDR95.99 - 98.6998.70 - 99.99----------100.00
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling431Registry/QCDR20.00 - 44.1344.14 - 63.9163.92 - 77.4377.44 - 86.2686.27 - 92.6792.68 - 97.0797.08 - 99.99100.00
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair432Registry/QCDR----------------
Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair433Registry/QCDR----------------
Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair434Registry/QCDR----------------
Quality of Life Assessment For Patients With Primary Headache Disorders435Claims----------------
Quality of Life Assessment For Patients With Primary Headache Disorders435Registry/QCDR----------------
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques436Claims51.21 - 67.4867.49 - 76.6976.70 - 82.8882.89 - 87.6487.65 - 92.2592.26 - 96.5896.59 - 99.75>= 99.76
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques436Registry/QCDR64.68 - 73.7973.80 - 81.5181.52 - 89.0089.01 - 98.2098.21 - 99.99----100.00
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure437Claims----------------
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure437Registry/QCDR----------------
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease438EHR----------------
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease438Registry/QCDR61.47 - 65.4065.41 - 69.3169.32 - 71.6771.68 - 74.3774.38 - 77.2177.22 - 81.1781.18 - 87.22>= 87.23
Age Appropriate Screening Colonoscopy439Registry/QCDR----------------
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician .440Registry/QCDR----------------
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)441Registry/QCDR----------------
Persistence of Beta-Blocker Treatment After a Heart Attack442Registry/QCDR----------------
Non-Recommended Cervical Cancer Screening in Adolescent Females443Registry/QCDR----------------
Medication Management for People with Asthma444Registry/QCDR----------------
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)445Registry/QCDR----------------
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories446Registry/QCDR----------------
Chlamydia Screening and Follow Up447Registry/QCDR----------------
Appropriate Work Up Prior to Endometrial Ablation448Registry/QCDR----------------
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies449Registry/QCDR----------------
Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy450Registry/QCDR----------------
RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy451Registry/QCDR----------------
Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) 4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies452Registry/QCDR----------------
Proportion Receiving Chemotherapy in the Last 14 Days of Life453Registry/QCDR----------------
Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life454Registry/QCDR----------------
Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life455Registry/QCDR----------------
Proportion Not Admitted To Hospice456Registry/QCDR----------------
Proportion Admitted to Hospice for less than 3 days457Registry/QCDR----------------
Average Change in Back Pain following Lumbar Discectomy / Laminotomy459Registry/QCDR----------------
Average Change in Back Pain following Lumbar Fusion460Registry/QCDR----------------
Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy461Registry/QCDR----------------
Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy462EHR----------------
Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)463Registry/QCDR----------------
Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use464Registry/QCDR----------------
Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and.Interrogation of Ovarian Arteries465Registry/QCDR----------------
Developmental Screening in the First Three Years of Life467Registry/QCDR----------------

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