2019 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 collection type: Qualified Clinical Data Registry (QCDR) measures, MIPS Clinical Quality Measures (MIPS CQMs), eCQMs, CMS Web Interface measures, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey, and Part B Claims measures. In order to measure performance that is comparable across the spectrum of performance, benchmarks are established using historical data. Historical benchmarks are based on actual performance data from 2017 that was submitted to the Quality Payment Program (QPP) in 2017, except for the CAHPS surveys. For 2019 CAHPS for MIPS, we have not yet established benchmarks. 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. One can find more info on this CMS 2019 Quality Measure Benchmark Fact Sheet. An Excel version of the 2019 MIPS Quality Historic Benchmarks can be found here

We marked at blue measures that can earn a maximum score of 7 points. These measures were topped out in 2018 and also in 2019 (ie, second year in a row) and are subject to scoring cap of 7 points. Topped-out means that the national median performance rate is so high that there is no meaningfull difference in performance between clinicians.

 

Measure NameMeasure IDSubmission MethodDecile 3Decile 4Decile 5Decile 6Decile 7Decile 8Decile 9Decile 10
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1Claims44.44 - 29.0429.03 - 19.5219.51 - 14.7214.71 - 11.1211.11 - 8.348.33 - 5.575.56 - 2.79<= 2.78
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1EHR77.14 - 60.7960.78 - 48.4948.48 - 38.9038.89 - 31.6031.59 - 25.8825.87 - 20.5620.55 - 14.72<= 14.71
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)1Registry/QCDR68.31 - 50.6350.62 - 37.5137.50 - 28.7028.69 - 20.0120.00 - 13.6013.59 - 9.039.02 - 2.71<= 2.70
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)5EHR74.19 - 78.5678.57 - 82.1382.14 - 85.1885.19 - 87.9287.93 - 90.9090.91 - 93.7493.75 - 97.72>= 97.73
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)5Registry/QCDR93.33 - 96.9696.97 - 98.4098.41 - 99.99--------100
Coronary Artery Disease (CAD): Antiplatelet Therapy6Registry/QCDR84.13 - 87.9988.00 - 90.6690.67 - 92.8592.86 - 95.0995.10 - 97.0897.09 - 99.99--100.00
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)7EHR76.74 - 80.3080.31 - 83.1783.18 - 85.2885.29 - 87.1587.16 - 89.7389.74 - 91.9191.92 - 94.86>= 94.87
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)7Registry/QCDR96.17 - 98.1198.12 - 99.7699.77 - 99.99--------100.00
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)8EHR80.49 - 85.6185.62 - 88.9788.98 - 91.2991.30 - 93.0493.05 - 94.7394.74 - 96.3496.35 - 99.99100
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)8Registry/QCDR95.45 - 98.0598.06 - 99.2899.29 - 99.99--------100
Anti-Depressant Medication Management9EHR16.67 - 31.0631.07 - 42.1842.19 - 53.1553.16 - 71.7371.74 - 82.7882.79 - 88.8888.89 - 94.43>= 94.44
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation12Claims--------100   
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation12EHR79.11 - 86.5786.58 - 90.6190.62 - 93.8793.88 - 96.3196.32 - 98.0198.02 - 99.1099.11 - 99.99100
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation12Registry/QCDR96.47 - 99.1699.17 - 99.99----100   
Age-Related Macular Degeneration (AMD): Dilated Macular Examination14Claims--------100   
Age-Related Macular Degeneration (AMD): Dilated Macular Examination14Registry/QCDR76.54 - 89.8089.81 - 96.5396.54 - 99.7099.71 - 99.99100   
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care19Claims--------100   
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care19EHR33.90 - 47.6147.62 - 57.8857.89 - 67.0267.03 - 75.3675.37 - 82.4882.49 - 90.0290.03 - 95.99>= 96.00
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care19Registry/QCDR70.29 - 84.4184.42 - 92.7292.73 - 98.5698.57 - 99.99------100
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin21Claims99.17 - 99.99------100   
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin21Registry/QCDR98.67 - 99.99------100   
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)23Claims--------100   
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)23Registry/QCDR98.68 - 99.99------100   
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older24Claims32.35 - 63.6363.64 - 92.3092.31 - 96.2096.21 - 97.6197.62 - 100   
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older24Registry/QCDR26.32 - 45.0945.10 - 55.3155.32 - 60.2060.21 - 69.9970.00 - 80.5580.56 - 99.99--100
Screening for Osteoporosis for Women Aged 65-85 Years of Age39Claims32.79 - 42.3642.37 - 49.0049.01 - 55.9055.91 - 62.5462.55 - 70.6870.69 - 82.8882.89 - 95.49>= 95.50
Screening for Osteoporosis for Women Aged 65-85 Years of Age39Registry/QCDR11.38 - 22.4322.44 - 34.7134.72 - 45.2545.26 - 58.1058.11 - 67.9767.98 - 78.4578.46 - 88.23>= 88.24
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery44Registry/QCDR90.35 - 95.8995.90 - 97.3897.39 - 99.99--100   
Medication Reconciliation Post-Discharge46Claims95.74 - 98.4098.41 - 99.99----100   
Medication Reconciliation Post-Discharge46Registry/QCDR94.24 - 97.6297.63 - 99.9299.93 - 99.99--100   
Care Plan47Claims50.32 - 82.6082.61 - 92.8892.89 - 97.4597.46 - 99.3099.31 - 99.99----100
Care Plan47Registry/QCDR24.33 - 45.0145.02 - 65.7465.75 - 82.1682.17 - 91.8991.90 - 97.3197.32 - 99.7199.72 - 99.99100
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older48Claims3.88 - 13.8513.86 - 72.4072.41 - 96.6896.69 - 99.99100   
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older48Registry/QCDR12.22 - 31.7431.75 - 52.3652.37 - 70.4470.45 - 84.2684.27 - 95.1095.11 - 99.5099.51 - 99.99100
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older50Claims97.30 - 98.8798.88 - 99.99----100   
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older50Registry/QCDR47.22 - 59.9960.00 - 68.9868.99 - 75.6375.64 - 85.4985.50 - 92.5892.59 - 99.6599.66 - 99.99100
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation51Claims38.10 - 77.2677.27 - 92.4492.45 - 98.7598.76 - 99.99100   
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation51Registry/QCDR25.00 - 45.4445.45 - 60.4260.43 - 75.7575.76 - 86.4586.46 - 93.8293.83 - 99.3599.36 - 99.99100
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy52Claims90.14 - 98.1498.15 - 99.99----100   
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy52Registry/QCDR90.16 - 95.2195.22 - 96.4896.49 - 98.8598.86 - 99.99100   
Appropriate Treatment for Children with Upper Respiratory Infection (URI)65EHR80.95 - 88.3688.37 - 91.7691.77 - 93.8793.88 - 95.6095.61 - 96.8796.88 - 98.2198.22 - 99.99100
Appropriate Treatment for Children with Upper Respiratory Infection (URI)65Registry/QCDR91.49 - 95.0195.02 - 97.0297.03 - 97.8497.85 - 98.6998.70 - 100   
Appropriate Testing for Children with Pharyngitis66EHR36.71 - 60.0460.05 - 72.4072.41 - 78.3778.38 - 83.3283.33 - 87.6287.63 - 91.4291.43 - 94.58>= 94.59
Appropriate Testing for Children with Pharyngitis66Registry/QCDR64.57 - 69.6069.61 - 75.4175.42 - 81.7481.75 - 85.5085.51 - 87.9587.96 - 91.7791.78 - 97.54>= 97.55
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow67Registry/QCDR8.00 - 12.4912.50 - 22.7222.73 - 28.5228.53 - 34.6134.62 - 78.7878.79 - 99.99--100
Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy68Registry/QCDR----------------
Hematology: Multiple Myeloma: Treatment with Bisphosphonates69Registry/QCDR42.86 - 47.4947.50 - 64.5164.52 - 66.6666.67 - 71.4271.43 - 71.8771.88 - 76.9176.92 - 92.30>= 92.31
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry70Registry/QCDR16.67 - 23.2023.21 - 32.2532.26 - 35.9435.95 - 67.8567.86 - 95.4495.45 - 99.99--100
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections76Claims95.24 - 98.6098.61 - 99.99----100   
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections76Registry/QCDR95.67 - 99.0899.09 - 99.99----100   
Acute Otitis Externa (AOE): Topical Therapy91Claims43.36 - 86.6086.61 - 93.2193.22 - 99.6599.66 - 99.99100   
Acute Otitis Externa (AOE): Topical Therapy91Registry/QCDR67.34 - 78.7678.77 - 86.3386.34 - 91.3291.33 - 95.2395.24 - 97.3697.37 - 99.99--100
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use93Claims89.12 - 93.5093.51 - 96.3596.36 - 97.8297.83 - 99.9299.93 - 100   
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use93Registry/QCDR63.16 - 77.3577.36 - 83.9683.97 - 89.6589.66 - 93.3293.33 - 96.1496.15 - 99.99--100
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients102EHR59.34 - 75.7375.74 - 83.9083.91 - 91.9992.00 - 98.3098.31 - 99.99----100
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients102Registry/QCDR----------------
Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer104Registry/QCDR39.65 - 48.1648.17 - 55.0555.06 - 76.2276.23 - 93.2593.26 - 99.5999.60 - 99.99--100
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment107EHR1.51 - 3.563.57 - 8.108.11 - 17.4817.49 - 30.2830.29 - 54.7254.73 - 77.5677.57 - 96.66>= 96.67
Osteoarthritis (OA): Function and Pain Assessment109Claims87.28 - 95.7195.72 - 98.7198.72 - 99.8899.89 - 99.99100   
Osteoarthritis (OA): Function and Pain Assessment109Registry/QCDR34.62 - 63.0063.01 - 86.6386.64 - 94.3794.38 - 99.99------100
Preventive Care and Screening: Influenza Immunization110Claims29.52 - 41.4141.42 - 56.3156.32 - 71.1871.19 - 82.8882.89 - 94.1494.15 - 99.4199.42 - 99.99100
Preventive Care and Screening: Influenza Immunization110EHR15.50 - 23.6323.64 - 31.2031.21 - 38.6538.66 - 46.7646.77 - 56.0156.02 - 67.4967.50 - 84.98>= 84.99
Preventive Care and Screening: Influenza Immunization110Registry/QCDR29.85 - 41.4241.43 - 53.8453.85 - 66.0266.03 - 76.9376.94 - 87.8087.81 - 96.4096.41 - 99.99100
Pneumococcal Vaccination Status for Older Adults111Claims49.76 - 61.1061.11 - 70.1070.11 - 77.3177.32 - 82.9582.96 - 89.4389.44 - 95.6695.67 - 99.99100
Pneumococcal Vaccination Status for Older Adults111EHR19.01 - 31.0631.07 - 42.7042.71 - 53.4353.44 - 62.8562.86 - 71.8171.82 - 80.4280.43 - 90.40&>= 90.41
Pneumococcal Vaccination Status for Older Adults111Registry/QCDR30.23 - 44.5244.53 - 55.5555.56 - 63.6363.64 - 70.4270.43 - 76.3776.38 - 83.7683.77 - 95.44>= 95.45
Breast Cancer Screening112Claims44.44 - 52.0752.08 - 58.4458.45 - 64.2864.29 - 70.9670.97 - 79.8479.85 - 90.2390.24 - 99.99100
Breast Cancer Screening112EHR22.28 - 32.7432.75 - 42.3142.32 - 51.0551.06 - 58.4358.44 - 65.6765.68 - 73.4373.44 - 82.30>= 82.31
Breast Cancer Screening112Registry/QCDR35.99 - 48.2548.26 - 57.5757.58 - 67.3867.39 - 75.2475.25 - 85.3085.31 - 93.4493.45 - 99.99100
Colorectal Cancer Screening113Claims36.60 - 50.9951.00 - 62.4962.50 - 71.2271.23 - 79.9980.00 - 88.6388.64 - 97.7297.73 - 99.99100
Colorectal Cancer Screening113EHR13.49 - 24.0024.01 - 33.9633.97 - 44.3844.39 - 54.7954.80 - 64.0064.01 - 73.3773.38 - 83.50>= 83.51
Colorectal Cancer Screening113Registry/QCDR35.90 - 49.5049.51 - 60.8260.83 - 70.8770.88 - 80.6180.62 - 90.4090.41 - 96.9796.98 - 99.99100
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis116Registry/QCDR44.27 - 57.0757.08 - 72.0272.03 - 83.7783.78 - 90.9890.99 - 95.5695.57 - 97.5497.55 - 99.99100
Diabetes: Eye Exam117Claims72.00 - 96.8796.88 - 99.99----100   
Diabetes: Eye Exam117EHR20.61 - 31.9932.00 - 45.5245.53 - 66.0166.02 - 89.1189.12 - 95.6495.65 - 98.2598.26 - 99.72>= 99.73
Diabetes: Eye Exam117Registry/QCDR77.26 - 89.9990.00 - 95.8195.82 - 98.4898.49 - 99.99100   
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)118Registry/QCDR76.00 - 78.5678.57 - 81.0781.08 - 83.9083.91 - 86.3586.36 - 88.7288.73 - 92.2592.26 - 98.17>= 98.18
Diabetes: Medical Attention for Nephropathy119EHR67.86 - 74.7974.80 - 79.9980.00 - 84.1384.14 - 87.7387.74 - 91.1091.11 - 94.6294.63 - 98.38>= 98.39
Diabetes: Medical Attention for Nephropathy119Registry/QCDR74.38 - 82.8582.86 - 87.7087.71 - 91.9391.94 - 97.2397.24 - 99.99----100
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation126Registry/QCDR66.15 - 85.2285.23 - 96.4296.43 - 99.99--------100
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear127Registry/QCDR70.59 - 92.8592.86 - 99.4599.46 - 99.99--------100
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan128Claims37.52 - 47.7747.78 - 74.4774.48 - 95.1995.20 - 99.2699.27 - 99.99----100
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan128EHR21.15 - 24.5824.59 - 28.5128.52 - 34.2034.21 - 43.8443.85 - 60.3060.31 - 78.2478.25 - 93.28>= 93.29
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan128Registry/QCDR34.35 - 54.2554.26 - 74.5674.57 - 90.5990.60 - 97.5597.56 - 99.8699.87 - 99.99--100
Documentation of Current Medications in the Medical Record130Claims97.95 - 99.5199.52 - 99.9199.92 - 99.99--100   
Documentation of Current Medications in the Medical Record130EHR87.55 - 93.4893.49 - 96.2896.29 - 97.9897.99 - 98.9999.00 - 100   
Documentation of Current Medications in the Medical Record130Registry/QCDR68.06 - 90.2790.28 - 97.2397.24 - 99.5099.51 - 99.99100   
Pain Assessment and Follow-Up131Claims80.57 - 96.9196.92 - 99.6399.64 - 99.99--100   
Pain Assessment and Follow-Up131Registry/QCDR15.80 - 39.9940.00 - 62.7862.79 - 84.0584.06 - 95.2595.26 - 99.5499.55 - 99.99--100
Preventive Care and Screening: Screening for Depression and Follow-Up Plan134Claims12.94 - 53.9153.92 - 80.2280.23 - 96.9896.99 - 99.99------100
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan134EHR4.88 - 10.1710.18 - 17.5917.60 - 28.2828.29 - 42.2942.30 - 56.8256.83 - 73.2973.30 - 87.49>= 87.50
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan134Registry/QCDR17.11 - 45.6445.65 - 73.8173.82 - 90.0590.06 - 98.4998.50 - 99.99----100
Melanoma: Continuity of Care - Recall System137Registry/QCDR83.83 - 94.3394.34 - 98.7998.80 - 99.99--------100
Melanoma: Coordination of Care138Registry/QCDR49.44 - 63.6363.64 - 78.2578.26 - 92.5892.59 - 99.99------100
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care141Claims--------100   
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care141Registry/QCDR73.85 - 87.4987.50 - 96.2996.30 - 99.3099.31 - 99.99------100
Oncology: Medical and Radiation - Pain Intensity Quantified143EHR77.21 - 87.7887.79 - 94.9194.92 - 97.2697.27 - 98.3498.35 - 100   
Oncology: Medical and Radiation - Pain Intensity Quantified143Registry/QCDR90.31 - 95.3995.40 - 97.1297.13 - 98.5698.57 - 99.2599.26 - 100   
Oncology: Medical and Radiation - Plan of Care for Pain144Registry/QCDR48.64 - 80.3880.39 - 89.8889.89 - 94.3394.34 - 98.4398.44 - 99.99----100
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy145Claims66.41 - 82.9282.93 - 90.9090.91 - 95.1795.18 - 97.3997.40 - 99.0699.07 - 99.99--100
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy145Registry/QCDR73.10 - 88.0388.04 - 94.9194.92 - 98.1598.16 - 99.5399.54 - 99.99----100
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms146Claims0.23 - 0.01------0   
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms146Registry/QCDR0.24 - 0.120.11 - 0.050.04 - 0.01--0   
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy147Claims76.47 - 87.1787.18 - 94.0594.06 - 97.0097.01 - 99.99------100
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy147Registry/QCDR93.04 - 97.9697.97 - 99.99----100   
Falls: Risk Assessment154Claims96.95 - 99.99------100   
Falls: Risk Assessment154Registry/QCDR28.63 - 60.8160.82 - 84.9985.00 - 95.9695.97 - 99.7399.74 - 100   
Falls: Plan of Care155Claims55.81 - 84.6184.62 - 99.2099.21 - 99.99--100   
Falls: Plan of Care155Registry/QCDR67.86 - 86.7886.79 - 94.9995.00 - 98.2198.22 - 99.99100   
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis160EHR----------------
Coronary Artery Bypass Graft (CABG): Prolonged Intubation164Registry/QCDR11.40 - 9.109.09 - 7.707.69 - 6.816.80 - 5.565.55 - 4.294.28 - 3.093.08 - 1.55<= 1.54
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate165Registry/QCDR0.84 - 0.01------0   
Coronary Artery Bypass Graft (CABG): Stroke166Registry/QCDR2.38 - 1.801.79 - 1.271.26 - 0.720.71 - 0.010   
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure167Registry/QCDR3.51 - 2.712.70 - 2.162.15 - 1.861.85 - 1.291.28 - 0   
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration168Registry/QCDR3.95 - 3.143.13 - 2.642.63 - 1.801.79 - 1.281.27 - 0.880.87 - 0.01--0
Rheumatoid Arthritis (RA): Tuberculosis Screening176Registry/QCDR32.00 - 48.1448.15 - 55.5555.56 - 68.0068.01 - 80.4280.43 - 99.0399.04 - 99.99--100
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity177Registry/QCDR57.23 - 74.9975.00 - 88.2388.24 - 96.0196.02 - 99.99------100
Rheumatoid Arthritis (RA): Functional Status Assessment178Registry/QCDR67.61 - 81.3981.40 - 90.5890.59 - 95.9495.95 - 99.99------100
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis179Registry/QCDR44.53 - 67.8867.89 - 85.3085.31 - 95.2195.22 - 99.99------100
Rheumatoid Arthritis (RA): Glucocorticoid Management180Registry/QCDR52.68 - 75.7875.79 - 87.9587.96 - 95.0595.06 - 99.5799.58 - 99.99----100
Elder Maltreatment Screen and Follow-Up Plan181Claims55.38 - 97.3197.32 - 99.5599.56 - 99.99--100   
Elder Maltreatment Screen and Follow-Up Plan181Registry/QCDR50.65 - 66.0366.04 - 77.7777.78 - 89.2889.29 - 96.7896.79 - 99.99----100
Functional Outcome Assessment182Claims--------100   
Functional Outcome Assessment182Registry/QCDR----------------
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use185Claims98.57 - 99.99------100   
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use185Registry/QCDR61.64 - 84.9985.00 - 90.5390.54 - 95.4195.42 - 98.4098.41 - 99.99----100
Stroke and Stroke Rehabilitation: Thrombolytic Therapy187Registry/QCDR88.89 - 96.4896.49 - 99.99----------100
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery191EHR85.25 - 90.6290.63 - 93.4093.41 - 95.5895.59 - 96.8796.88 - 97.8297.83 - 98.7798.78 - 99.99100
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery191Registry/QCDR94.37 - 96.8796.88 - 98.9798.98 - 99.99--------100
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures192EHR--------0   
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures192Registry/QCDR--------0   
Radiology: Stenosis Measurement in Carotid Imaging Reports195Claims91.72 - 96.2296.23 - 98.1798.18 - 99.99--100   
Radiology: Stenosis Measurement in Carotid Imaging Reports195Registry/QCDR97.81 - 99.8499.85 - 99.99----100   
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 Other General Orthopaedic Impairments223Registry/QCDR----------------
Radiology: Reminder System for Screening Mammograms225Claims99.36 - 99.99------100   
Radiology: Reminder System for Screening Mammograms225Registry/QCDR--------------100
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention226Claims----------------
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention226EHR----------------
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention226Registry/QCDR----------------
Controlling High Blood Pressure236Claims58.57 - 63.9763.98 - 68.8268.83 - 73.9073.91 - 78.5678.57 - 83.3283.33 - 88.3188.32 - 94.88>= 94.89
Controlling High Blood Pressure236EHR51.46 - 56.8256.83 - 60.9460.95 - 64.6764.68 - 68.1768.18 - 72.0072.01 - 76.2576.26 - 82.20>= 82.21
Controlling High Blood Pressure236Registry/QCDR52.41 - 60.0460.05 - 65.6765.68 - 70.6170.62 - 76.8276.83 - 84.6184.62 - 93.3993.40 - 99.99100
Use of High-Risk Medications in the Elderly238EHR8.04 - 4.754.74 - 2.682.67 - 1.321.31 - 0.540.53 - 0   
Use of High-Risk Medications in the Elderly238Registry/QCDR0.68 - 0.290.28 - 0.140.13 - 0.01--0   
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents239EHR26.23 - 29.5129.52 - 31.4731.48 - 32.7932.80 - 33.8533.86 - 38.7238.73 - 47.7647.77 - 65.52>= 65.53
Childhood Immunization Status240EHR9.30 - 14.8014.81 - 20.4920.50 - 26.6726.68 - 30.6630.67 - 37.2237.23 - 42.4142.42 - 50.88>= 50.89
Cardiac Rehabilitation Patient Referral from an Outpatient Setting243Registry/QCDR8.11 - 11.8711.88 - 14.6214.63 - 17.2217.23 - 20.7720.78 - 24.3124.32 - 30.6830.69 - 44.43>= 44.44
Barrett's Esophagus249Claims--------100   
Barrett's Esophagus249Registry/QCDR--------100   
Radical Prostatectomy Pathology Reporting250Claims--------------100
Radical Prostatectomy Pathology Reporting250Registry/QCDR--------100   
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain254Claims----------------
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain254Registry/QCDR74.42 - 80.9480.95 - 85.3685.37 - 88.8888.89 - 91.9992.00 - 95.2395.24 - 97.6697.67 - 99.99100
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----------------
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   
Sentinel Lymph Node Biopsy for Invasive Breast Cancer264Registry/QCDR97.96 - 99.2199.22 - 99.99----100   
Biopsy Follow-Up265Registry/QCDR61.23 - 83.6283.63 - 95.6495.65 - 99.3799.38 - 99.99100   
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy268Claims----------------
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy268Registry/QCDR32.00 - 45.3445.35 - 57.1357.14 - 78.5678.57 - 95.9996.00 - 99.0699.07 - 99.99--100
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: Severity Assessment at Initial Diagnosis277Registry/QCDR69.01 - 81.0281.03 - 90.6290.63 - 99.7099.71 - 99.99------100
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy279Registry/QCDR90.08 - 96.2696.27 - 99.1699.17 - 99.99--------100
Dementia: Cognitive Assessment281EHR5.88 - 12.8912.90 - 26.0826.09 - 44.9945.00 - 59.2559.26 - 73.3273.33 - 88.5688.57 - 96.76>= 96.77
Dementia: Functional Status Assessment282Registry/QCDR57.14 - 78.9478.95 - 95.2795.28 - 99.1299.13 - 99.99------100
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management283Registry/QCDR58.14 - 83.0783.08 - 96.6696.67 - 99.8199.82 - 99.99------100
Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia286Registry/QCDR62.86 - 78.6878.69 - 89.8889.89 - 98.2098.21 - 99.99------100
Dementia: Caregiver Education and Support288Registry/QCDR59.26 - 77.3277.33 - 89.3289.33 - 97.5397.54 - 99.99------100
Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease290Registry/QCDR85.09 - 92.5592.56 - 96.9196.92 - 99.2299.23 - 99.99100   
Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment291Registry/QCDR86.49 - 94.9995.00 - 99.99----------100
Parkinson's Disease: Rehabilitative Therapy Options293Registry/QCDR67.03 - 82.9482.95 - 94.2894.29 - 99.99--------100
Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery303Registry/QCDR45.11 - 70.8770.88 - 78.7678.77 - 84.9084.91 - 91.7791.78 - 98.7998.80 - 99.99--100
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery304Registry/QCDR50.00 - 72.2172.22 - 80.2980.30 - 87.0887.09 - 95.4195.42 - 99.1199.12 - 99.99--100
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment305EHR0.31 - 0.410.42 - 0.670.68 - 1.021.03 - 1.341.35 - 2.232.24 - 3.843.85 - 6.90>= 6.91
Cervical Cancer Screening309EHR9.83 - 16.7916.80 - 23.6523.66 - 31.5331.54 - 39.7139.72 - 48.3048.31 - 57.6257.63 - 72.60>= 72.61
Chlamydia Screening for Women310EHR16.67 - 22.3022.31 - 28.0428.05 - 33.3233.33 - 39.1239.13 - 44.7744.78 - 53.1353.14 - 63.77>= 63.78
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented317Claims34.25 - 45.4745.48 - 58.4858.49 - 73.2873.29 - 89.4089.41 - 98.0698.07 - 99.99--100
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented317EHR19.56 - 24.1324.14 - 28.1828.19 - 32.3032.31 - 36.6636.67 - 42.1142.12 - 50.6950.70 - 74.54>= 74.55
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented317Registry/QCDR25.75 - 30.8030.81 - 35.4635.47 - 42.5642.57 - 59.1459.15 - 83.4883.49 - 97.3197.32 - 99.99100
Falls: Screening for Future Fall Risk318EHR7.24 - 20.2620.27 - 36.4036.41 - 52.2452.25 - 66.7266.73 - 78.5978.60 - 88.5088.51 - 96.55>= 96.56
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients320Claims95.24 - 97.7297.73 - 99.99----100   
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients320Registry/QCDR85.00 - 89.7389.74 - 93.6093.61 - 95.9495.95 - 97.7297.73 - 100   
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients322Registry/QCDR1.90 - 0.01------0   
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)323Registry/QCDR2.44 - 0.01------0   
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients324Registry/QCDR6.25 - 2.022.01 - 0.01----------0
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions325Registry/QCDR----------------
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy326Claims84.13 - 95.2895.29 - 98.7998.80 - 99.99--100   
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy326Registry/QCDR69.54 - 75.1075.11 - 78.8978.90 - 83.0883.09 - 88.1688.17 - 94.9394.94 - 99.99--100
Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/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 Viral Sinusitis (Overuse)331Registry/QCDR92.15 - 87.5187.50 - 82.8982.88 - 75.3775.36 - 64.3664.35 - 46.6846.67 - 20.0019.99 - 0.010
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)332Registry/QCDR93.55 - 96.1996.20 - 97.5897.59 - 98.3998.40 - 99.3599.36 - 99.99----100
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)333Registry/QCDR2.50 - 0.910.90 - 0.270.26 - 0.01--0   
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----------------
Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier337Registry/QCDR47.06 - 60.6060.61 - 73.6273.63 - 82.5082.51 - 89.9990.00 - 96.4296.43 - 99.99--100
HIV Viral Load Suppression338Registry/QCDR74.47 - 78.5678.57 - 83.9984.00 - 87.9387.94 - 93.9994.00 - 97.2397.24 - 99.99--100
HIV Medical Visit Frequency340Registry/QCDR48.97 - 52.8552.86 - 61.0861.09 - 82.6882.69 - 87.9988.00 - 92.8592.86 - 95.9195.92 - 99.99100
Pain Brought Under Control Within 48 Hours342Registry/QCDR98.78 - 99.99------------100
Screening Colonoscopy Adenoma Detection Rate343Registry/QCDR30.32 - 34.2534.26 - 38.8038.81 - 42.0742.08 - 45.8445.85 - 50.1450.15 - 59.1959.20 - 85.24>= 85.25
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)344Registry/QCDR----------------
Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive345Registry/QCDR----------------
Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive346Registry/QCDR----------------
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive347Registry/QCDR----------------
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate348Registry/QCDR----------------
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy350Registry/QCDR96.00 - 99.99------------100
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation351Registry/QCDR--------------100
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet352Registry/QCDR--------------100
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report353Registry/QCDR--------------100
Anastomotic Leak Intervention354Registry/QCDR3.61 - 3.243.23 - 0.740.73 - 0.01--------0
Unplanned Reoperation within the 30 Day Postoperative Period355Registry/QCDR3.15 - 2.282.27 - 1.221.21 - 0.410.40 - 0.01------0
Unplanned Hospital Readmission within 30 Days of Principal Procedure356Registry/QCDR5.00 - 3.313.30 - 2.012.00 - 0.01--------0
Surgical Site Infection (SSI)357Registry/QCDR3.48 - 2.282.27 - 0.940.93 - 0.01--------0
Patient-Centered Surgical Risk Assessment and Communication358Registry/QCDR17.29 - 61.7861.79 - 91.4291.43 - 97.6397.64 - 99.99100   
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies360Registry/QCDR31.53 - 61.3761.38 - 90.5490.55 - 98.8298.83 - 99.99------100
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry361Registry/QCDR--------------100
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison362Registry/QCDR--------------100
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines364Registry/QCDR59.02 - 93.2493.25 - 97.6497.65 - 99.8099.81 - 99.99------100
Follow-Up Care for Children Prescribed ADHD Medication (ADD)366EHR26.67 - 30.8630.87 - 33.9533.96 - 38.0938.10 - 46.4546.46 - 48.8348.84 - 54.5454.55 - 65.90>= 65.91
Depression Remission at Twelve Months370EHR2.08 - 2.692.70 - 3.693.70 - 4.344.35 - 5.315.32 - 7.137.14 - 8.768.77 - 14.99>= 15.00
Depression Remission at Twelve Months370Registry/QCDR----------------
Depression Utilization of the PHQ-9 Tool371EHR3.82 - 6.116.12 - 9.089.09 - 12.6812.69 - 16.6616.67 - 22.0822.09 - 30.2930.30 - 43.13>= 43.14
Maternal Depression Screening372EHR----------------
Closing the Referral Loop: Receipt of Specialist Report374EHR7.63 - 14.9714.98 - 26.3226.33 - 36.7336.74 - 48.1448.15 - 60.2460.25 - 74.4374.44 - 90.74>= 90.75
Closing the Referral Loop: Receipt of Specialist Report374Registry/QCDR6.77 - 8.508.51 - 37.8337.84 - 62.8562.86 - 82.4282.43 - 88.8888.89 - 92.7392.74 - 99.01>= 99.02
Functional Status Assessment for Total Knee Replacement375EHR5.00 - 9.679.68 - 15.9015.91 - 20.3020.31 - 24.5524.56 - 34.3734.38 - 53.4153.42 - 77.26>= 77.27
Functional Status Assessment for Total Hip Replacement376EHR4.82 - 8.508.51 - 13.0913.10 - 19.2219.23 - 27.5827.59 - 33.3233.33 - 40.1840.19 - 63.48>= 63.49
Functional Status Assessments for Congestive Heart Failure377EHR----------------
Children Who Have Dental Decay or Cavities378EHR0.47 - 0.100.09 - 0.01----0   
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists379EHR0.32 - 0.540.55 - 0.730.74 - 1.081.09 - 2.072.08 - 3.213.22 - 4.894.90 - 9.04>= 9.05
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment382EHR3.43 - 7.007.01 - 12.4612.47 - 14.8314.84 - 20.2520.26 - 29.0029.01 - 36.1036.11 - 51.71>= 51.72
Adherence to Antipsychotic Medications For Individuals with Schizophrenia383Registry/QCDR58.00 - 71.4271.43 - 86.8386.84 - 90.0090.01 - 98.3298.33 - 99.99----100
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/QCDR0.38 - 0.450.46 - 0.580.59 - 0.760.77 - 1.311.32 - 1.401.41 - 1.601.61 - 2.86>= 2.87
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)388Registry/QCDR--------0   
Cataract Surgery: Difference Between Planned and Final Refraction389Registry/QCDR77.17 - 90.9090.91 - 96.9696.97 - 99.2199.22 - 99.99------100
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options390Registry/QCDR63.64 - 80.8680.87 - 95.4495.45 - 99.99--------100
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)395Claims--------100   
Lung Cancer Reporting (Biopsy/Cytology Specimens)395Registry/QCDR--------100   
Lung Cancer Reporting (Resection Specimens)396Claims----------------
Lung Cancer Reporting (Resection Specimens)396Registry/QCDR--------------100
Melanoma Reporting397Claims--------100   
Melanoma Reporting397Registry/QCDR91.96 - 99.99------100   
Optimal Asthma Control398Registry/QCDR33.52 - 59.4559.46 - 74.9975.00 - 95.9996.00 - 98.9898.99 - 99.99----100
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk400Registry/QCDR1.26 - 1.841.85 - 3.223.23 - 6.306.31 - 16.7716.78 - 24.1024.11 - 32.0032.01 - 74.59>= 74.60
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis401Registry/QCDR----------------
Tobacco Use and Help with Quitting Among Adolescents402Registry/QCDR86.36 - 91.1791.18 - 94.1194.12 - 96.1196.12 - 97.5897.59 - 98.8398.84 - 99.99--100
Adult Kidney Disease: Referral to Hospice403Registry/QCDR----------------
Anesthesiology Smoking Abstinence404Registry/QCDR39.88 - 50.5850.59 - 57.2457.25 - 62.9963.00 - 69.7469.75 - 75.2675.27 - 82.4082.41 - 93.37>= 93.38
Appropriate Follow-up Imaging for Incidental Abdominal Lesions405Claims10.26 - 4.454.44 - 0.730.72 - 0.01--------0
Appropriate Follow-up Imaging for Incidental Abdominal Lesions405Registry/QCDR12.11 - 6.686.67 - 2.642.63 - 0.540.53 - 0.01------0
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients406Claims61.90 - 48.0148.00 - 37.5137.50 - 15.5715.56 - 2.572.56 - 0.01----0
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients406Registry/QCDR14.94 - 5.985.97 - 3.653.64 - 0.100.09 - 0.01------0
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia407Claims----------------
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia407Registry/QCDR--------------100
Opioid Therapy Follow-up Evaluation408Registry/QCDR68.35 - 91.3591.36 - 98.4898.49 - 99.99 100   
Clinical Outcome Post Endovascular Stroke Treatment409Registry/QCDR----------------
Psoriasis: Clinical Response to Oral Systemic or Biologic Medications410Registry/QCDR23.08 - 36.3536.36 - 49.9950.00 - 61.5361.54 - 72.2172.22 - 87.4987.50 - 97.2197.22 - 99.99100
Depression Remission at Six Months411Registry/QCDR----------------
Documentation of Signed Opioid Treatment Agreement412Registry/QCDR61.17 - 88.3488.35 - 97.4397.44 - 99.6699.67 - 99.99100   
Door to Puncture Time for Endovascular Stroke Treatment413Registry/QCDR----------------
Evaluation or Interview for Risk of Opioid Misuse414Registry/QCDR88.55 - 98.5998.60 - 99.99----100   
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older415Claims96.00 - 99.99------100   
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older415Registry/QCDR63.41 - 69.9970.00 - 76.1876.19 - 80.3680.37 - 83.4583.46 - 86.4886.49 - 89.6089.61 - 98.20>= 98.21
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years416Registry/QCDR46.67 - 40.0140.00 - 35.0135.00 - 28.3828.37 - 22.8222.81 - 18.7618.75 - 14.8214.81 - 9.53<= 9.52
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years416Claims----------------
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/QCDR----------------
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination419Registry/QCDR74.74 - 85.7085.71 - 91.2991.30 - 95.7095.71 - 99.99------100
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination419Claims----------------
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 Temperature Management424Registry/QCDR98.46 - 99.5199.52 - 99.7499.75 - 99.8799.88 - 99.99100   
Photodocumentation of Cecal Intubation425Claims97.44 - 98.4898.49 - 99.1599.16 - 99.99--100   
Photodocumentation of Cecal Intubation425Registry/QCDR97.59 - 98.3198.32 - 98.7398.74 - 99.0499.05 - 99.2999.30 - 100   
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/QCDR93.66 - 97.1797.18 - 98.5398.54 - 99.2199.22 - 99.6399.64 - 100   
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling431Registry/QCDR33.43 - 49.3449.35 - 66.1166.12 - 78.1278.13 - 86.9987.00 - 93.5193.52 - 97.9597.96 - 99.99100
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 Disorders435Registry/QCDR2.05 - 3.023.03 - 5.495.50 - 12.4312.44 - 25.8125.82 - 75.8575.86 - 99.99--100
Quality of Life Assessment For Patients With Primary Headache Disorders435Claims----------------
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques436Claims85.73 - 94.1294.13 - 97.4597.46 - 98.9598.96 - 99.6599.66 - 99.99----100
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques436Registry/QCDR93.28 - 96.9696.97 - 99.0599.06 - 99.6699.67 - 99.9199.92 - 99.99----100
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure437Claims1.32 - 0.560.55 - 0.01----------0
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure437Registry/QCDR----------------
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease438EHR63.75 - 71.0671.07 - 77.1177.12 - 84.2684.27 - 99.99------100
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease438Registry/QCDR78.72 - 91.6691.67 - 95.6495.65 - 97.3797.38 - 99.99------100
Age Appropriate Screening Colonoscopy439Registry/QCDR----------------
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician .440Registry/QCDR96.91 - 98.9598.96 - 99.8799.88 - 99.99--------100
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)441Registry/QCDR32.40 - 37.1337.14 - 40.1640.17 - 44.0344.04 - 47.7747.78 - 50.6150.62 - 54.3554.36 - 58.25>= 58.26
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/QCDR91.67 - 95.9996.00 - 97.7797.78 - 98.4398.44 - 99.99------100
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)445Registry/QCDR3.90 - 3.173.16 - 2.692.68 - 2.252.24 - 1.731.72 - 1.231.22 - 0.01--0
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories446Registry/QCDR----------------
Appropriate Work Up Prior to Endometrial Ablation448Registry/QCDR----------------
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies449Registry/QCDR95.71 - 98.5298.53 - 99.99----------100
Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy450Registry/QCDR90.00 - 90.9090.91 - 93.5493.55 - 99.99--------100
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/QCDR15.00 - 10.4310.42 - 9.199.18 - 8.007.99 - 7.367.35 - 7.047.03 - 2.392.38 - 0.010
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/QCDR15.38 - 15.0115.00 - 13.5213.51 - 11.1111.10 - 9.659.64 - 6.466.45 - 0.01--0
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----------------
Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)468Registry/QCDR----------------
Average Change in Functional Status Following Lumbar Fusion Surgery469Registry/QCDR----------------
Average Change In Functional Status Following Total Knee Replacement Surgery470Registry/QCDR----------------
Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery471Registry/QCDR----------------
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture472EHR----------------
Average Change in Leg Pain Following Lumbar Fusion Surgery473Registry/QCDR----------------
Zoster (Shingles) Vaccination474Registry/QCDR----------------
HIV Screening475EHR----------------

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