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 meaningful difference in performance between clinicians.
| Measure Name | Measure ID | Submission Method | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 |
|---|---|---|---|---|---|---|---|---|---|---|
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | Claims | 44.44 - 29.04 | 29.03 - 19.52 | 19.51 - 14.72 | 14.71 - 11.12 | 11.11 - 8.34 | 8.33 - 5.57 | 5.56 - 2.79 | <= 2.78 |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | EHR | 77.14 - 60.79 | 60.78 - 48.49 | 48.48 - 38.90 | 38.89 - 31.60 | 31.59 - 25.88 | 25.87 - 20.56 | 20.55 - 14.72 | <= 14.71 |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | Registry/QCDR | 68.31 - 50.63 | 50.62 - 37.51 | 37.50 - 28.70 | 28.69 - 20.01 | 20.00 - 13.60 | 13.59 - 9.03 | 9.02 - 2.71 | <= 2.70 |
| Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 5 | EHR | 74.19 - 78.56 | 78.57 - 82.13 | 82.14 - 85.18 | 85.19 - 87.92 | 87.93 - 90.90 | 90.91 - 93.74 | 93.75 - 97.72 | >= 97.73 |
| Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 5 | Registry/QCDR | 93.33 - 96.96 | 96.97 - 98.40 | 98.41 - 99.99 | -- | -- | -- | -- | 100 |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | 6 | Registry/QCDR | 84.13 - 87.99 | 88.00 - 90.66 | 90.67 - 92.85 | 92.86 - 95.09 | 95.10 - 97.08 | 97.09 - 99.99 | -- | 100.00 |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) | 7 | EHR | 76.74 - 80.30 | 80.31 - 83.17 | 83.18 - 85.28 | 85.29 - 87.15 | 87.16 - 89.73 | 89.74 - 91.91 | 91.92 - 94.86 | >= 94.87 |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) | 7 | Registry/QCDR | 96.17 - 98.11 | 98.12 - 99.76 | 99.77 - 99.99 | -- | -- | -- | -- | 100.00 |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | EHR | 80.49 - 85.61 | 85.62 - 88.97 | 88.98 - 91.29 | 91.30 - 93.04 | 93.05 - 94.73 | 94.74 - 96.34 | 96.35 - 99.99 | 100 |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | Registry/QCDR | 95.45 - 98.05 | 98.06 - 99.28 | 99.29 - 99.99 | -- | -- | -- | -- | 100 |
| Anti-Depressant Medication Management | 9 | EHR | 16.67 - 31.06 | 31.07 - 42.18 | 42.19 - 53.15 | 53.16 - 71.73 | 71.74 - 82.78 | 82.79 - 88.88 | 88.89 - 94.43 | >= 94.44 |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | Claims | -- | -- | -- | -- | 100 | |||
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | EHR | 79.11 - 86.57 | 86.58 - 90.61 | 90.62 - 93.87 | 93.88 - 96.31 | 96.32 - 98.01 | 98.02 - 99.10 | 99.11 - 99.99 | 100 |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | Registry/QCDR | 96.47 - 99.16 | 99.17 - 99.99 | -- | -- | 100 | |||
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | Claims | -- | -- | -- | -- | 100 | |||
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | Registry/QCDR | 76.54 - 89.80 | 89.81 - 96.53 | 96.54 - 99.70 | 99.71 - 99.99 | 100 | |||
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | Claims | -- | -- | -- | -- | 100 | |||
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | EHR | 33.90 - 47.61 | 47.62 - 57.88 | 57.89 - 67.02 | 67.03 - 75.36 | 75.37 - 82.48 | 82.49 - 90.02 | 90.03 - 95.99 | >= 96.00 |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | Registry/QCDR | 70.29 - 84.41 | 84.42 - 92.72 | 92.73 - 98.56 | 98.57 - 99.99 | -- | -- | -- | 100 |
| Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin | 21 | Claims | 99.17 - 99.99 | -- | -- | -- | 100 | |||
| Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin | 21 | Registry/QCDR | 98.67 - 99.99 | -- | -- | -- | 100 | |||
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | Claims | -- | -- | -- | -- | 100 | |||
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | Registry/QCDR | 98.68 - 99.99 | -- | -- | -- | 100 | |||
| Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | 24 | Claims | 32.35 - 63.63 | 63.64 - 92.30 | 92.31 - 96.20 | 96.21 - 97.61 | 97.62 - 100 | |||
| Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | 24 | Registry/QCDR | 26.32 - 45.09 | 45.10 - 55.31 | 55.32 - 60.20 | 60.21 - 69.99 | 70.00 - 80.55 | 80.56 - 99.99 | -- | 100 |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | Claims | 32.79 - 42.36 | 42.37 - 49.00 | 49.01 - 55.90 | 55.91 - 62.54 | 62.55 - 70.68 | 70.69 - 82.88 | 82.89 - 95.49 | >= 95.50 |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | Registry/QCDR | 11.38 - 22.43 | 22.44 - 34.71 | 34.72 - 45.25 | 45.26 - 58.10 | 58.11 - 67.97 | 67.98 - 78.45 | 78.46 - 88.23 | >= 88.24 |
| Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | 44 | Registry/QCDR | 90.35 - 95.89 | 95.90 - 97.38 | 97.39 - 99.99 | -- | 100 | |||
| Medication Reconciliation Post-Discharge | 46 | Claims | 95.74 - 98.40 | 98.41 - 99.99 | -- | -- | 100 | |||
| Medication Reconciliation Post-Discharge | 46 | Registry/QCDR | 94.24 - 97.62 | 97.63 - 99.92 | 99.93 - 99.99 | -- | 100 | |||
| Care Plan | 47 | Claims | 50.32 - 82.60 | 82.61 - 92.88 | 92.89 - 97.45 | 97.46 - 99.30 | 99.31 - 99.99 | -- | -- | 100 |
| Care Plan | 47 | Registry/QCDR | 24.33 - 45.01 | 45.02 - 65.74 | 65.75 - 82.16 | 82.17 - 91.89 | 91.90 - 97.31 | 97.32 - 99.71 | 99.72 - 99.99 | 100 |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | Claims | 3.88 - 13.85 | 13.86 - 72.40 | 72.41 - 96.68 | 96.69 - 99.99 | 100 | |||
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | Registry/QCDR | 12.22 - 31.74 | 31.75 - 52.36 | 52.37 - 70.44 | 70.45 - 84.26 | 84.27 - 95.10 | 95.11 - 99.50 | 99.51 - 99.99 | 100 |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | Claims | 97.30 - 98.87 | 98.88 - 99.99 | -- | -- | 100 | |||
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | Registry/QCDR | 47.22 - 59.99 | 60.00 - 68.98 | 68.99 - 75.63 | 75.64 - 85.49 | 85.50 - 92.58 | 92.59 - 99.65 | 99.66 - 99.99 | 100 |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 51 | Claims | 38.10 - 77.26 | 77.27 - 92.44 | 92.45 - 98.75 | 98.76 - 99.99 | 100 | |||
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 51 | Registry/QCDR | 25.00 - 45.44 | 45.45 - 60.42 | 60.43 - 75.75 | 75.76 - 86.45 | 86.46 - 93.82 | 93.83 - 99.35 | 99.36 - 99.99 | 100 |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | Claims | 90.14 - 98.14 | 98.15 - 99.99 | -- | -- | 100 | |||
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | Registry/QCDR | 90.16 - 95.21 | 95.22 - 96.48 | 96.49 - 98.85 | 98.86 - 99.99 | 100 | |||
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | EHR | 80.95 - 88.36 | 88.37 - 91.76 | 91.77 - 93.87 | 93.88 - 95.60 | 95.61 - 96.87 | 96.88 - 98.21 | 98.22 - 99.99 | 100 |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | Registry/QCDR | 91.49 - 95.01 | 95.02 - 97.02 | 97.03 - 97.84 | 97.85 - 98.69 | 98.70 - 100 | |||
| Appropriate Testing for Children with Pharyngitis | 66 | EHR | 36.71 - 60.04 | 60.05 - 72.40 | 72.41 - 78.37 | 78.38 - 83.32 | 83.33 - 87.62 | 87.63 - 91.42 | 91.43 - 94.58 | >= 94.59 |
| Appropriate Testing for Children with Pharyngitis | 66 | Registry/QCDR | 64.57 - 69.60 | 69.61 - 75.41 | 75.42 - 81.74 | 81.75 - 85.50 | 85.51 - 87.95 | 87.96 - 91.77 | 91.78 - 97.54 | >= 97.55 |
| Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | 67 | Registry/QCDR | 8.00 - 12.49 | 12.50 - 22.72 | 22.73 - 28.52 | 28.53 - 34.61 | 34.62 - 78.78 | 78.79 - 99.99 | -- | 100 |
| Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | 68 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Hematology: Multiple Myeloma: Treatment with Bisphosphonates | 69 | Registry/QCDR | 42.86 - 47.49 | 47.50 - 64.51 | 64.52 - 66.66 | 66.67 - 71.42 | 71.43 - 71.87 | 71.88 - 76.91 | 76.92 - 92.30 | >= 92.31 |
| Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | 70 | Registry/QCDR | 16.67 - 23.20 | 23.21 - 32.25 | 32.26 - 35.94 | 35.95 - 67.85 | 67.86 - 95.44 | 95.45 - 99.99 | -- | 100 |
| Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 76 | Claims | 95.24 - 98.60 | 98.61 - 99.99 | -- | -- | 100 | |||
| Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 76 | Registry/QCDR | 95.67 - 99.08 | 99.09 - 99.99 | -- | -- | 100 | |||
| Acute Otitis Externa (AOE): Topical Therapy | 91 | Claims | 43.36 - 86.60 | 86.61 - 93.21 | 93.22 - 99.65 | 99.66 - 99.99 | 100 | |||
| Acute Otitis Externa (AOE): Topical Therapy | 91 | Registry/QCDR | 67.34 - 78.76 | 78.77 - 86.33 | 86.34 - 91.32 | 91.33 - 95.23 | 95.24 - 97.36 | 97.37 - 99.99 | -- | 100 |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | 93 | Claims | 89.12 - 93.50 | 93.51 - 96.35 | 96.36 - 97.82 | 97.83 - 99.92 | 99.93 - 100 | |||
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | 93 | Registry/QCDR | 63.16 - 77.35 | 77.36 - 83.96 | 83.97 - 89.65 | 89.66 - 93.32 | 93.33 - 96.14 | 96.15 - 99.99 | -- | 100 |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | EHR | 59.34 - 75.73 | 75.74 - 83.90 | 83.91 - 91.99 | 92.00 - 98.30 | 98.31 - 99.99 | -- | -- | 100 |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | 104 | Registry/QCDR | 39.65 - 48.16 | 48.17 - 55.05 | 55.06 - 76.22 | 76.23 - 93.25 | 93.26 - 99.59 | 99.60 - 99.99 | -- | 100 |
| Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 107 | EHR | 1.51 - 3.56 | 3.57 - 8.10 | 8.11 - 17.48 | 17.49 - 30.28 | 30.29 - 54.72 | 54.73 - 77.56 | 77.57 - 96.66 | >= 96.67 |
| Osteoarthritis (OA): Function and Pain Assessment | 109 | Claims | 87.28 - 95.71 | 95.72 - 98.71 | 98.72 - 99.88 | 99.89 - 99.99 | 100 | |||
| Osteoarthritis (OA): Function and Pain Assessment | 109 | Registry/QCDR | 34.62 - 63.00 | 63.01 - 86.63 | 86.64 - 94.37 | 94.38 - 99.99 | -- | -- | -- | 100 |
| Preventive Care and Screening: Influenza Immunization | 110 | Claims | 29.52 - 41.41 | 41.42 - 56.31 | 56.32 - 71.18 | 71.19 - 82.88 | 82.89 - 94.14 | 94.15 - 99.41 | 99.42 - 99.99 | 100 |
| Preventive Care and Screening: Influenza Immunization | 110 | EHR | 15.50 - 23.63 | 23.64 - 31.20 | 31.21 - 38.65 | 38.66 - 46.76 | 46.77 - 56.01 | 56.02 - 67.49 | 67.50 - 84.98 | >= 84.99 |
| Preventive Care and Screening: Influenza Immunization | 110 | Registry/QCDR | 29.85 - 41.42 | 41.43 - 53.84 | 53.85 - 66.02 | 66.03 - 76.93 | 76.94 - 87.80 | 87.81 - 96.40 | 96.41 - 99.99 | 100 |
| Pneumococcal Vaccination Status for Older Adults | 111 | Claims | 49.76 - 61.10 | 61.11 - 70.10 | 70.11 - 77.31 | 77.32 - 82.95 | 82.96 - 89.43 | 89.44 - 95.66 | 95.67 - 99.99 | 100 |
| Pneumococcal Vaccination Status for Older Adults | 111 | EHR | 19.01 - 31.06 | 31.07 - 42.70 | 42.71 - 53.43 | 53.44 - 62.85 | 62.86 - 71.81 | 71.82 - 80.42 | 80.43 - 90.40 | &>= 90.41 |
| Pneumococcal Vaccination Status for Older Adults | 111 | Registry/QCDR | 30.23 - 44.52 | 44.53 - 55.55 | 55.56 - 63.63 | 63.64 - 70.42 | 70.43 - 76.37 | 76.38 - 83.76 | 83.77 - 95.44 | >= 95.45 |
| Breast Cancer Screening | 112 | Claims | 44.44 - 52.07 | 52.08 - 58.44 | 58.45 - 64.28 | 64.29 - 70.96 | 70.97 - 79.84 | 79.85 - 90.23 | 90.24 - 99.99 | 100 |
| Breast Cancer Screening | 112 | EHR | 22.28 - 32.74 | 32.75 - 42.31 | 42.32 - 51.05 | 51.06 - 58.43 | 58.44 - 65.67 | 65.68 - 73.43 | 73.44 - 82.30 | >= 82.31 |
| Breast Cancer Screening | 112 | Registry/QCDR | 35.99 - 48.25 | 48.26 - 57.57 | 57.58 - 67.38 | 67.39 - 75.24 | 75.25 - 85.30 | 85.31 - 93.44 | 93.45 - 99.99 | 100 |
| Colorectal Cancer Screening | 113 | Claims | 36.60 - 50.99 | 51.00 - 62.49 | 62.50 - 71.22 | 71.23 - 79.99 | 80.00 - 88.63 | 88.64 - 97.72 | 97.73 - 99.99 | 100 |
| Colorectal Cancer Screening | 113 | EHR | 13.49 - 24.00 | 24.01 - 33.96 | 33.97 - 44.38 | 44.39 - 54.79 | 54.80 - 64.00 | 64.01 - 73.37 | 73.38 - 83.50 | >= 83.51 |
| Colorectal Cancer Screening | 113 | Registry/QCDR | 35.90 - 49.50 | 49.51 - 60.82 | 60.83 - 70.87 | 70.88 - 80.61 | 80.62 - 90.40 | 90.41 - 96.97 | 96.98 - 99.99 | 100 |
| Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | 116 | Registry/QCDR | 44.27 - 57.07 | 57.08 - 72.02 | 72.03 - 83.77 | 83.78 - 90.98 | 90.99 - 95.56 | 95.57 - 97.54 | 97.55 - 99.99 | 100 |
| Diabetes: Eye Exam | 117 | Claims | 72.00 - 96.87 | 96.88 - 99.99 | -- | -- | 100 | |||
| Diabetes: Eye Exam | 117 | EHR | 20.61 - 31.99 | 32.00 - 45.52 | 45.53 - 66.01 | 66.02 - 89.11 | 89.12 - 95.64 | 95.65 - 98.25 | 98.26 - 99.72 | >= 99.73 |
| Diabetes: Eye Exam | 117 | Registry/QCDR | 77.26 - 89.99 | 90.00 - 95.81 | 95.82 - 98.48 | 98.49 - 99.99 | 100 | |||
| Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 118 | Registry/QCDR | 76.00 - 78.56 | 78.57 - 81.07 | 81.08 - 83.90 | 83.91 - 86.35 | 86.36 - 88.72 | 88.73 - 92.25 | 92.26 - 98.17 | >= 98.18 |
| Diabetes: Medical Attention for Nephropathy | 119 | EHR | 67.86 - 74.79 | 74.80 - 79.99 | 80.00 - 84.13 | 84.14 - 87.73 | 87.74 - 91.10 | 91.11 - 94.62 | 94.63 - 98.38 | >= 98.39 |
| Diabetes: Medical Attention for Nephropathy | 119 | Registry/QCDR | 74.38 - 82.85 | 82.86 - 87.70 | 87.71 - 91.93 | 91.94 - 97.23 | 97.24 - 99.99 | -- | -- | 100 |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation | 126 | Registry/QCDR | 66.15 - 85.22 | 85.23 - 96.42 | 96.43 - 99.99 | -- | -- | -- | -- | 100 |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear | 127 | Registry/QCDR | 70.59 - 92.85 | 92.86 - 99.45 | 99.46 - 99.99 | -- | -- | -- | -- | 100 |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Claims | 37.52 - 47.77 | 47.78 - 74.47 | 74.48 - 95.19 | 95.20 - 99.26 | 99.27 - 99.99 | -- | -- | 100 |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | EHR | 21.15 - 24.58 | 24.59 - 28.51 | 28.52 - 34.20 | 34.21 - 43.84 | 43.85 - 60.30 | 60.31 - 78.24 | 78.25 - 93.28 | >= 93.29 |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Registry/QCDR | 34.35 - 54.25 | 54.26 - 74.56 | 74.57 - 90.59 | 90.60 - 97.55 | 97.56 - 99.86 | 99.87 - 99.99 | -- | 100 |
| Documentation of Current Medications in the Medical Record | 130 | Claims | 97.95 - 99.51 | 99.52 - 99.91 | 99.92 - 99.99 | -- | 100 | |||
| Documentation of Current Medications in the Medical Record | 130 | EHR | 87.55 - 93.48 | 93.49 - 96.28 | 96.29 - 97.98 | 97.99 - 98.99 | 99.00 - 100 | |||
| Documentation of Current Medications in the Medical Record | 130 | Registry/QCDR | 68.06 - 90.27 | 90.28 - 97.23 | 97.24 - 99.50 | 99.51 - 99.99 | 100 | |||
| Pain Assessment and Follow-Up | 131 | Claims | 80.57 - 96.91 | 96.92 - 99.63 | 99.64 - 99.99 | -- | 100 | |||
| Pain Assessment and Follow-Up | 131 | Registry/QCDR | 15.80 - 39.99 | 40.00 - 62.78 | 62.79 - 84.05 | 84.06 - 95.25 | 95.26 - 99.54 | 99.55 - 99.99 | -- | 100 |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | Claims | 12.94 - 53.91 | 53.92 - 80.22 | 80.23 - 96.98 | 96.99 - 99.99 | -- | -- | -- | 100 |
| Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 134 | EHR | 4.88 - 10.17 | 10.18 - 17.59 | 17.60 - 28.28 | 28.29 - 42.29 | 42.30 - 56.82 | 56.83 - 73.29 | 73.30 - 87.49 | >= 87.50 |
| Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 134 | Registry/QCDR | 17.11 - 45.64 | 45.65 - 73.81 | 73.82 - 90.05 | 90.06 - 98.49 | 98.50 - 99.99 | -- | -- | 100 |
| Melanoma: Continuity of Care - Recall System | 137 | Registry/QCDR | 83.83 - 94.33 | 94.34 - 98.79 | 98.80 - 99.99 | -- | -- | -- | -- | 100 |
| Melanoma: Coordination of Care | 138 | Registry/QCDR | 49.44 - 63.63 | 63.64 - 78.25 | 78.26 - 92.58 | 92.59 - 99.99 | -- | -- | -- | 100 |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Claims | -- | -- | -- | -- | 100 | |||
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Registry/QCDR | 73.85 - 87.49 | 87.50 - 96.29 | 96.30 - 99.30 | 99.31 - 99.99 | -- | -- | -- | 100 |
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | EHR | 77.21 - 87.78 | 87.79 - 94.91 | 94.92 - 97.26 | 97.27 - 98.34 | 98.35 - 100 | |||
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | Registry/QCDR | 90.31 - 95.39 | 95.40 - 97.12 | 97.13 - 98.56 | 98.57 - 99.25 | 99.26 - 100 | |||
| Oncology: Medical and Radiation - Plan of Care for Pain | 144 | Registry/QCDR | 48.64 - 80.38 | 80.39 - 89.88 | 89.89 - 94.33 | 94.34 - 98.43 | 98.44 - 99.99 | -- | -- | 100 |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | Claims | 66.41 - 82.92 | 82.93 - 90.90 | 90.91 - 95.17 | 95.18 - 97.39 | 97.40 - 99.06 | 99.07 - 99.99 | -- | 100 |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | Registry/QCDR | 73.10 - 88.03 | 88.04 - 94.91 | 94.92 - 98.15 | 98.16 - 99.53 | 99.54 - 99.99 | -- | -- | 100 |
| Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | 146 | Claims | 0.23 - 0.01 | -- | -- | -- | 0 | |||
| Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | 146 | Registry/QCDR | 0.24 - 0.12 | 0.11 - 0.05 | 0.04 - 0.01 | -- | 0 | |||
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Claims | 76.47 - 87.17 | 87.18 - 94.05 | 94.06 - 97.00 | 97.01 - 99.99 | -- | -- | -- | 100 |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Registry/QCDR | 93.04 - 97.96 | 97.97 - 99.99 | -- | -- | 100 | |||
| Falls: Risk Assessment | 154 | Claims | 96.95 - 99.99 | -- | -- | -- | 100 | |||
| Falls: Risk Assessment | 154 | Registry/QCDR | 28.63 - 60.81 | 60.82 - 84.99 | 85.00 - 95.96 | 95.97 - 99.73 | 99.74 - 100 | |||
| Falls: Plan of Care | 155 | Claims | 55.81 - 84.61 | 84.62 - 99.20 | 99.21 - 99.99 | -- | 100 | |||
| Falls: Plan of Care | 155 | Registry/QCDR | 67.86 - 86.78 | 86.79 - 94.99 | 95.00 - 98.21 | 98.22 - 99.99 | 100 | |||
| HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | 160 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | Registry/QCDR | 11.40 - 9.10 | 9.09 - 7.70 | 7.69 - 6.81 | 6.80 - 5.56 | 5.55 - 4.29 | 4.28 - 3.09 | 3.08 - 1.55 | <= 1.54 |
| Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | 165 | Registry/QCDR | 0.84 - 0.01 | -- | -- | -- | 0 | |||
| Coronary Artery Bypass Graft (CABG): Stroke | 166 | Registry/QCDR | 2.38 - 1.80 | 1.79 - 1.27 | 1.26 - 0.72 | 0.71 - 0.01 | 0 | |||
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | Registry/QCDR | 3.51 - 2.71 | 2.70 - 2.16 | 2.15 - 1.86 | 1.85 - 1.29 | 1.28 - 0 | |||
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | Registry/QCDR | 3.95 - 3.14 | 3.13 - 2.64 | 2.63 - 1.80 | 1.79 - 1.28 | 1.27 - 0.88 | 0.87 - 0.01 | -- | 0 |
| Rheumatoid Arthritis (RA): Tuberculosis Screening | 176 | Registry/QCDR | 32.00 - 48.14 | 48.15 - 55.55 | 55.56 - 68.00 | 68.01 - 80.42 | 80.43 - 99.03 | 99.04 - 99.99 | -- | 100 |
| Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | Registry/QCDR | 57.23 - 74.99 | 75.00 - 88.23 | 88.24 - 96.01 | 96.02 - 99.99 | -- | -- | -- | 100 |
| Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | Registry/QCDR | 67.61 - 81.39 | 81.40 - 90.58 | 90.59 - 95.94 | 95.95 - 99.99 | -- | -- | -- | 100 |
| Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | 179 | Registry/QCDR | 44.53 - 67.88 | 67.89 - 85.30 | 85.31 - 95.21 | 95.22 - 99.99 | -- | -- | -- | 100 |
| Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | Registry/QCDR | 52.68 - 75.78 | 75.79 - 87.95 | 87.96 - 95.05 | 95.06 - 99.57 | 99.58 - 99.99 | -- | -- | 100 |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Claims | 55.38 - 97.31 | 97.32 - 99.55 | 99.56 - 99.99 | -- | 100 | |||
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Registry/QCDR | 50.65 - 66.03 | 66.04 - 77.77 | 77.78 - 89.28 | 89.29 - 96.78 | 96.79 - 99.99 | -- | -- | 100 |
| Functional Outcome Assessment | 182 | Claims | -- | -- | -- | -- | 100 | |||
| Functional Outcome Assessment | 182 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use | 185 | Claims | 98.57 - 99.99 | -- | -- | -- | 100 | |||
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use | 185 | Registry/QCDR | 61.64 - 84.99 | 85.00 - 90.53 | 90.54 - 95.41 | 95.42 - 98.40 | 98.41 - 99.99 | -- | -- | 100 |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | Registry/QCDR | 88.89 - 96.48 | 96.49 - 99.99 | -- | -- | -- | -- | -- | 100 |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | EHR | 85.25 - 90.62 | 90.63 - 93.40 | 93.41 - 95.58 | 95.59 - 96.87 | 96.88 - 97.82 | 97.83 - 98.77 | 98.78 - 99.99 | 100 |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | Registry/QCDR | 94.37 - 96.87 | 96.88 - 98.97 | 98.98 - 99.99 | -- | -- | -- | -- | 100 |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | EHR | -- | -- | -- | -- | 0 | |||
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | Registry/QCDR | -- | -- | -- | -- | 0 | |||
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Claims | 91.72 - 96.22 | 96.23 - 98.17 | 98.18 - 99.99 | -- | 100 | |||
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Registry/QCDR | 97.81 - 99.84 | 99.85 - 99.99 | -- | -- | 100 | |||
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Knee Impairments | 217 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Hip Impairments | 218 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Foot or Ankle Impairments | 219 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Lumbar Impairments | 220 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Shoulder Impairments | 221 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Other General Orthopaedic Impairments | 223 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Radiology: Reminder System for Screening Mammograms | 225 | Claims | 99.36 - 99.99 | -- | -- | -- | 100 | |||
| Radiology: Reminder System for Screening Mammograms | 225 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Controlling High Blood Pressure | 236 | Claims | 58.57 - 63.97 | 63.98 - 68.82 | 68.83 - 73.90 | 73.91 - 78.56 | 78.57 - 83.32 | 83.33 - 88.31 | 88.32 - 94.88 | >= 94.89 |
| Controlling High Blood Pressure | 236 | EHR | 51.46 - 56.82 | 56.83 - 60.94 | 60.95 - 64.67 | 64.68 - 68.17 | 68.18 - 72.00 | 72.01 - 76.25 | 76.26 - 82.20 | >= 82.21 |
| Controlling High Blood Pressure | 236 | Registry/QCDR | 52.41 - 60.04 | 60.05 - 65.67 | 65.68 - 70.61 | 70.62 - 76.82 | 76.83 - 84.61 | 84.62 - 93.39 | 93.40 - 99.99 | 100 |
| Use of High-Risk Medications in the Elderly | 238 | EHR | 8.04 - 4.75 | 4.74 - 2.68 | 2.67 - 1.32 | 1.31 - 0.54 | 0.53 - 0 | |||
| Use of High-Risk Medications in the Elderly | 238 | Registry/QCDR | 0.68 - 0.29 | 0.28 - 0.14 | 0.13 - 0.01 | -- | 0 | |||
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 239 | EHR | 26.23 - 29.51 | 29.52 - 31.47 | 31.48 - 32.79 | 32.80 - 33.85 | 33.86 - 38.72 | 38.73 - 47.76 | 47.77 - 65.52 | >= 65.53 |
| Childhood Immunization Status | 240 | EHR | 9.30 - 14.80 | 14.81 - 20.49 | 20.50 - 26.67 | 26.68 - 30.66 | 30.67 - 37.22 | 37.23 - 42.41 | 42.42 - 50.88 | >= 50.89 |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | Registry/QCDR | 8.11 - 11.87 | 11.88 - 14.62 | 14.63 - 17.22 | 17.23 - 20.77 | 20.78 - 24.31 | 24.32 - 30.68 | 30.69 - 44.43 | >= 44.44 |
| Barrett's Esophagus | 249 | Claims | -- | -- | -- | -- | 100 | |||
| Barrett's Esophagus | 249 | Registry/QCDR | -- | -- | -- | -- | 100 | |||
| Radical Prostatectomy Pathology Reporting | 250 | Claims | -- | -- | -- | -- | -- | -- | -- | 100 |
| Radical Prostatectomy Pathology Reporting | 250 | Registry/QCDR | -- | -- | -- | -- | 100 | |||
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Registry/QCDR | 74.42 - 80.94 | 80.95 - 85.36 | 85.37 - 88.88 | 88.89 - 91.99 | 92.00 - 95.23 | 95.24 - 97.66 | 97.67 - 99.99 | 100 |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Registry/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) | 258 | Registry/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) | 259 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Image Confirmation of Successful Excision of Image-Localized Breast Lesion | 262 | Registry/QCDR | -- | -- | -- | -- | 100 | |||
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | Registry/QCDR | 97.96 - 99.21 | 99.22 - 99.99 | -- | -- | 100 | |||
| Biopsy Follow-Up | 265 | Registry/QCDR | 61.23 - 83.62 | 83.63 - 95.64 | 95.65 - 99.37 | 99.38 - 99.99 | 100 | |||
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Registry/QCDR | 32.00 - 45.34 | 45.35 - 57.13 | 57.14 - 78.56 | 78.57 - 95.99 | 96.00 - 99.06 | 99.07 - 99.99 | -- | 100 |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment | 271 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Sleep Apnea: Severity Assessment at Initial Diagnosis | 277 | Registry/QCDR | 69.01 - 81.02 | 81.03 - 90.62 | 90.63 - 99.70 | 99.71 - 99.99 | -- | -- | -- | 100 |
| Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | 279 | Registry/QCDR | 90.08 - 96.26 | 96.27 - 99.16 | 99.17 - 99.99 | -- | -- | -- | -- | 100 |
| Dementia: Cognitive Assessment | 281 | EHR | 5.88 - 12.89 | 12.90 - 26.08 | 26.09 - 44.99 | 45.00 - 59.25 | 59.26 - 73.32 | 73.33 - 88.56 | 88.57 - 96.76 | >= 96.77 |
| Dementia: Functional Status Assessment | 282 | Registry/QCDR | 57.14 - 78.94 | 78.95 - 95.27 | 95.28 - 99.12 | 99.13 - 99.99 | -- | -- | -- | 100 |
| Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | 283 | Registry/QCDR | 58.14 - 83.07 | 83.08 - 96.66 | 96.67 - 99.81 | 99.82 - 99.99 | -- | -- | -- | 100 |
| Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia | 286 | Registry/QCDR | 62.86 - 78.68 | 78.69 - 89.88 | 89.89 - 98.20 | 98.21 - 99.99 | -- | -- | -- | 100 |
| Dementia: Caregiver Education and Support | 288 | Registry/QCDR | 59.26 - 77.32 | 77.33 - 89.32 | 89.33 - 97.53 | 97.54 - 99.99 | -- | -- | -- | 100 |
| Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease | 290 | Registry/QCDR | 85.09 - 92.55 | 92.56 - 96.91 | 96.92 - 99.22 | 99.23 - 99.99 | 100 | |||
| Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment | 291 | Registry/QCDR | 86.49 - 94.99 | 95.00 - 99.99 | -- | -- | -- | -- | -- | 100 |
| Parkinson's Disease: Rehabilitative Therapy Options | 293 | Registry/QCDR | 67.03 - 82.94 | 82.95 - 94.28 | 94.29 - 99.99 | -- | -- | -- | -- | 100 |
| Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | 303 | Registry/QCDR | 45.11 - 70.87 | 70.88 - 78.76 | 78.77 - 84.90 | 84.91 - 91.77 | 91.78 - 98.79 | 98.80 - 99.99 | -- | 100 |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | Registry/QCDR | 50.00 - 72.21 | 72.22 - 80.29 | 80.30 - 87.08 | 87.09 - 95.41 | 95.42 - 99.11 | 99.12 - 99.99 | -- | 100 |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | EHR | 0.31 - 0.41 | 0.42 - 0.67 | 0.68 - 1.02 | 1.03 - 1.34 | 1.35 - 2.23 | 2.24 - 3.84 | 3.85 - 6.90 | >= 6.91 |
| Cervical Cancer Screening | 309 | EHR | 9.83 - 16.79 | 16.80 - 23.65 | 23.66 - 31.53 | 31.54 - 39.71 | 39.72 - 48.30 | 48.31 - 57.62 | 57.63 - 72.60 | >= 72.61 |
| Chlamydia Screening for Women | 310 | EHR | 16.67 - 22.30 | 22.31 - 28.04 | 28.05 - 33.32 | 33.33 - 39.12 | 39.13 - 44.77 | 44.78 - 53.13 | 53.14 - 63.77 | >= 63.78 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Claims | 34.25 - 45.47 | 45.48 - 58.48 | 58.49 - 73.28 | 73.29 - 89.40 | 89.41 - 98.06 | 98.07 - 99.99 | -- | 100 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | EHR | 19.56 - 24.13 | 24.14 - 28.18 | 28.19 - 32.30 | 32.31 - 36.66 | 36.67 - 42.11 | 42.12 - 50.69 | 50.70 - 74.54 | >= 74.55 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Registry/QCDR | 25.75 - 30.80 | 30.81 - 35.46 | 35.47 - 42.56 | 42.57 - 59.14 | 59.15 - 83.48 | 83.49 - 97.31 | 97.32 - 99.99 | 100 |
| Falls: Screening for Future Fall Risk | 318 | EHR | 7.24 - 20.26 | 20.27 - 36.40 | 36.41 - 52.24 | 52.25 - 66.72 | 66.73 - 78.59 | 78.60 - 88.50 | 88.51 - 96.55 | >= 96.56 |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Claims | 95.24 - 97.72 | 97.73 - 99.99 | -- | -- | 100 | |||
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Registry/QCDR | 85.00 - 89.73 | 89.74 - 93.60 | 93.61 - 95.94 | 95.95 - 97.72 | 97.73 - 100 | |||
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | 322 | Registry/QCDR | 1.90 - 0.01 | -- | -- | -- | 0 | |||
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | 323 | Registry/QCDR | 2.44 - 0.01 | -- | -- | -- | 0 | |||
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | 324 | Registry/QCDR | 6.25 - 2.02 | 2.01 - 0.01 | -- | -- | -- | -- | -- | 0 |
| Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | 325 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Claims | 84.13 - 95.28 | 95.29 - 98.79 | 98.80 - 99.99 | -- | 100 | |||
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Registry/QCDR | 69.54 - 75.10 | 75.11 - 78.89 | 78.90 - 83.08 | 83.09 - 88.16 | 88.17 - 94.93 | 94.94 - 99.99 | -- | 100 |
| Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL | 328 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | 329 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | 330 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | Registry/QCDR | 92.15 - 87.51 | 87.50 - 82.89 | 82.88 - 75.37 | 75.36 - 64.36 | 64.35 - 46.68 | 46.67 - 20.00 | 19.99 - 0.01 | 0 |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | Registry/QCDR | 93.55 - 96.19 | 96.20 - 97.58 | 97.59 - 98.39 | 98.40 - 99.35 | 99.36 - 99.99 | -- | -- | 100 |
| Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | 333 | Registry/QCDR | 2.50 - 0.91 | 0.90 - 0.27 | 0.26 - 0.01 | -- | 0 | |||
| Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) | 335 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Maternity Care: Post-Partum Follow-Up and Care Coordination | 336 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier | 337 | Registry/QCDR | 47.06 - 60.60 | 60.61 - 73.62 | 73.63 - 82.50 | 82.51 - 89.99 | 90.00 - 96.42 | 96.43 - 99.99 | -- | 100 |
| HIV Viral Load Suppression | 338 | Registry/QCDR | 74.47 - 78.56 | 78.57 - 83.99 | 84.00 - 87.93 | 87.94 - 93.99 | 94.00 - 97.23 | 97.24 - 99.99 | -- | 100 |
| HIV Medical Visit Frequency | 340 | Registry/QCDR | 48.97 - 52.85 | 52.86 - 61.08 | 61.09 - 82.68 | 82.69 - 87.99 | 88.00 - 92.85 | 92.86 - 95.91 | 95.92 - 99.99 | 100 |
| Pain Brought Under Control Within 48 Hours | 342 | Registry/QCDR | 98.78 - 99.99 | -- | -- | -- | -- | -- | -- | 100 |
| Screening Colonoscopy Adenoma Detection Rate | 343 | Registry/QCDR | 30.32 - 34.25 | 34.26 - 38.80 | 38.81 - 42.07 | 42.08 - 45.84 | 45.85 - 50.14 | 50.15 - 59.19 | 59.20 - 85.24 | >= 85.25 |
| Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | 344 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive | 345 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive | 346 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive | 347 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | 348 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | 350 | Registry/QCDR | 96.00 - 99.99 | -- | -- | -- | -- | -- | -- | 100 |
| Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | 351 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | 352 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | 353 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Anastomotic Leak Intervention | 354 | Registry/QCDR | 3.61 - 3.24 | 3.23 - 0.74 | 0.73 - 0.01 | -- | -- | -- | -- | 0 |
| Unplanned Reoperation within the 30 Day Postoperative Period | 355 | Registry/QCDR | 3.15 - 2.28 | 2.27 - 1.22 | 1.21 - 0.41 | 0.40 - 0.01 | -- | -- | -- | 0 |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | 356 | Registry/QCDR | 5.00 - 3.31 | 3.30 - 2.01 | 2.00 - 0.01 | -- | -- | -- | -- | 0 |
| Surgical Site Infection (SSI) | 357 | Registry/QCDR | 3.48 - 2.28 | 2.27 - 0.94 | 0.93 - 0.01 | -- | -- | -- | -- | 0 |
| Patient-Centered Surgical Risk Assessment and Communication | 358 | Registry/QCDR | 17.29 - 61.78 | 61.79 - 91.42 | 91.43 - 97.63 | 97.64 - 99.99 | 100 | |||
| Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | 360 | Registry/QCDR | 31.53 - 61.37 | 61.38 - 90.54 | 90.55 - 98.82 | 98.83 - 99.99 | -- | -- | -- | 100 |
| Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | 361 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison | 362 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 364 | Registry/QCDR | 59.02 - 93.24 | 93.25 - 97.64 | 97.65 - 99.80 | 99.81 - 99.99 | -- | -- | -- | 100 |
| Follow-Up Care for Children Prescribed ADHD Medication (ADD) | 366 | EHR | 26.67 - 30.86 | 30.87 - 33.95 | 33.96 - 38.09 | 38.10 - 46.45 | 46.46 - 48.83 | 48.84 - 54.54 | 54.55 - 65.90 | >= 65.91 |
| Depression Remission at Twelve Months | 370 | EHR | 2.08 - 2.69 | 2.70 - 3.69 | 3.70 - 4.34 | 4.35 - 5.31 | 5.32 - 7.13 | 7.14 - 8.76 | 8.77 - 14.99 | >= 15.00 |
| Depression Remission at Twelve Months | 370 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Depression Utilization of the PHQ-9 Tool | 371 | EHR | 3.82 - 6.11 | 6.12 - 9.08 | 9.09 - 12.68 | 12.69 - 16.66 | 16.67 - 22.08 | 22.09 - 30.29 | 30.30 - 43.13 | >= 43.14 |
| Maternal Depression Screening | 372 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | EHR | 7.63 - 14.97 | 14.98 - 26.32 | 26.33 - 36.73 | 36.74 - 48.14 | 48.15 - 60.24 | 60.25 - 74.43 | 74.44 - 90.74 | >= 90.75 |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | Registry/QCDR | 6.77 - 8.50 | 8.51 - 37.83 | 37.84 - 62.85 | 62.86 - 82.42 | 82.43 - 88.88 | 88.89 - 92.73 | 92.74 - 99.01 | >= 99.02 |
| Functional Status Assessment for Total Knee Replacement | 375 | EHR | 5.00 - 9.67 | 9.68 - 15.90 | 15.91 - 20.30 | 20.31 - 24.55 | 24.56 - 34.37 | 34.38 - 53.41 | 53.42 - 77.26 | >= 77.27 |
| Functional Status Assessment for Total Hip Replacement | 376 | EHR | 4.82 - 8.50 | 8.51 - 13.09 | 13.10 - 19.22 | 19.23 - 27.58 | 27.59 - 33.32 | 33.33 - 40.18 | 40.19 - 63.48 | >= 63.49 |
| Functional Status Assessments for Congestive Heart Failure | 377 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |
| Children Who Have Dental Decay or Cavities | 378 | EHR | 0.47 - 0.10 | 0.09 - 0.01 | -- | -- | 0 | |||
| Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 379 | EHR | 0.32 - 0.54 | 0.55 - 0.73 | 0.74 - 1.08 | 1.09 - 2.07 | 2.08 - 3.21 | 3.22 - 4.89 | 4.90 - 9.04 | >= 9.05 |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | EHR | 3.43 - 7.00 | 7.01 - 12.46 | 12.47 - 14.83 | 14.84 - 20.25 | 20.26 - 29.00 | 29.01 - 36.10 | 36.11 - 51.71 | >= 51.72 |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | Registry/QCDR | 58.00 - 71.42 | 71.43 - 86.83 | 86.84 - 90.00 | 90.01 - 98.32 | 98.33 - 99.99 | -- | -- | 100 |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | 386 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | 387 | Registry/QCDR | 0.38 - 0.45 | 0.46 - 0.58 | 0.59 - 0.76 | 0.77 - 1.31 | 1.32 - 1.40 | 1.41 - 1.60 | 1.61 - 2.86 | >= 2.87 |
| Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) | 388 | Registry/QCDR | -- | -- | -- | -- | 0 | |||
| Cataract Surgery: Difference Between Planned and Final Refraction | 389 | Registry/QCDR | 77.17 - 90.90 | 90.91 - 96.96 | 96.97 - 99.21 | 99.22 - 99.99 | -- | -- | -- | 100 |
| Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | 390 | Registry/QCDR | 63.64 - 80.86 | 80.87 - 95.44 | 95.45 - 99.99 | -- | -- | -- | -- | 100 |
| Follow-Up After Hospitalization for Mental Illness (FUH) | 391 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | 392 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | 393 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Immunizations for Adolescents | 394 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Claims | -- | -- | -- | -- | 100 | |||
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Registry/QCDR | -- | -- | -- | -- | 100 | |||
| Lung Cancer Reporting (Resection Specimens) | 396 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Lung Cancer Reporting (Resection Specimens) | 396 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Melanoma Reporting | 397 | Claims | -- | -- | -- | -- | 100 | |||
| Melanoma Reporting | 397 | Registry/QCDR | 91.96 - 99.99 | -- | -- | -- | 100 | |||
| Optimal Asthma Control | 398 | Registry/QCDR | 33.52 - 59.45 | 59.46 - 74.99 | 75.00 - 95.99 | 96.00 - 98.98 | 98.99 - 99.99 | -- | -- | 100 |
| One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | 400 | Registry/QCDR | 1.26 - 1.84 | 1.85 - 3.22 | 3.23 - 6.30 | 6.31 - 16.77 | 16.78 - 24.10 | 24.11 - 32.00 | 32.01 - 74.59 | >= 74.60 |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Tobacco Use and Help with Quitting Among Adolescents | 402 | Registry/QCDR | 86.36 - 91.17 | 91.18 - 94.11 | 94.12 - 96.11 | 96.12 - 97.58 | 97.59 - 98.83 | 98.84 - 99.99 | -- | 100 |
| Adult Kidney Disease: Referral to Hospice | 403 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Anesthesiology Smoking Abstinence | 404 | Registry/QCDR | 39.88 - 50.58 | 50.59 - 57.24 | 57.25 - 62.99 | 63.00 - 69.74 | 69.75 - 75.26 | 75.27 - 82.40 | 82.41 - 93.37 | >= 93.38 |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Claims | 10.26 - 4.45 | 4.44 - 0.73 | 0.72 - 0.01 | -- | -- | -- | -- | 0 |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Registry/QCDR | 12.11 - 6.68 | 6.67 - 2.64 | 2.63 - 0.54 | 0.53 - 0.01 | -- | -- | -- | 0 |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Claims | 61.90 - 48.01 | 48.00 - 37.51 | 37.50 - 15.57 | 15.56 - 2.57 | 2.56 - 0.01 | -- | -- | 0 |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Registry/QCDR | 14.94 - 5.98 | 5.97 - 3.65 | 3.64 - 0.10 | 0.09 - 0.01 | -- | -- | -- | 0 |
| Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | 407 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | 407 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | 100 |
| Opioid Therapy Follow-up Evaluation | 408 | Registry/QCDR | 68.35 - 91.35 | 91.36 - 98.48 | 98.49 - 99.99 | 100 | ||||
| Clinical Outcome Post Endovascular Stroke Treatment | 409 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Psoriasis: Clinical Response to Oral Systemic or Biologic Medications | 410 | Registry/QCDR | 23.08 - 36.35 | 36.36 - 49.99 | 50.00 - 61.53 | 61.54 - 72.21 | 72.22 - 87.49 | 87.50 - 97.21 | 97.22 - 99.99 | 100 |
| Depression Remission at Six Months | 411 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Documentation of Signed Opioid Treatment Agreement | 412 | Registry/QCDR | 61.17 - 88.34 | 88.35 - 97.43 | 97.44 - 99.66 | 99.67 - 99.99 | 100 | |||
| Door to Puncture Time for Endovascular Stroke Treatment | 413 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Evaluation or Interview for Risk of Opioid Misuse | 414 | Registry/QCDR | 88.55 - 98.59 | 98.60 - 99.99 | -- | -- | 100 | |||
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | Claims | 96.00 - 99.99 | -- | -- | -- | 100 | |||
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | Registry/QCDR | 63.41 - 69.99 | 70.00 - 76.18 | 76.19 - 80.36 | 80.37 - 83.45 | 83.46 - 86.48 | 86.49 - 89.60 | 89.61 - 98.20 | >= 98.21 |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Registry/QCDR | 46.67 - 40.01 | 40.00 - 35.01 | 35.00 - 28.38 | 28.37 - 22.82 | 22.81 - 18.76 | 18.75 - 14.82 | 14.81 - 9.53 | <= 9.52 |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive | 417 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination | 419 | Registry/QCDR | 74.74 - 85.70 | 85.71 - 91.29 | 91.30 - 95.70 | 95.71 - 99.99 | -- | -- | -- | 100 |
| Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination | 419 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | 420 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | 421 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Perioperative Temperature Management | 424 | Registry/QCDR | 98.46 - 99.51 | 99.52 - 99.74 | 99.75 - 99.87 | 99.88 - 99.99 | 100 | |||
| Photodocumentation of Cecal Intubation | 425 | Claims | 97.44 - 98.48 | 98.49 - 99.15 | 99.16 - 99.99 | -- | 100 | |||
| Photodocumentation of Cecal Intubation | 425 | Registry/QCDR | 97.59 - 98.31 | 98.32 - 98.73 | 98.74 - 99.04 | 99.05 - 99.29 | 99.30 - 100 | |||
| Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | 428 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy | 430 | Registry/QCDR | 93.66 - 97.17 | 97.18 - 98.53 | 98.54 - 99.21 | 99.22 - 99.63 | 99.64 - 100 | |||
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | Registry/QCDR | 33.43 - 49.34 | 49.35 - 66.11 | 66.12 - 78.12 | 78.13 - 86.99 | 87.00 - 93.51 | 93.52 - 97.95 | 97.96 - 99.99 | 100 |
| Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | 432 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 433 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair | 434 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Registry/QCDR | 2.05 - 3.02 | 3.03 - 5.49 | 5.50 - 12.43 | 12.44 - 25.81 | 25.82 - 75.85 | 75.86 - 99.99 | -- | 100 |
| Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Claims | -- | -- | -- | -- | -- | -- | -- | -- |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Claims | 85.73 - 94.12 | 94.13 - 97.45 | 97.46 - 98.95 | 98.96 - 99.65 | 99.66 - 99.99 | -- | -- | 100 |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Registry/QCDR | 93.28 - 96.96 | 96.97 - 99.05 | 99.06 - 99.66 | 99.67 - 99.91 | 99.92 - 99.99 | -- | -- | 100 |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Claims | 1.32 - 0.56 | 0.55 - 0.01 | -- | -- | -- | -- | -- | 0 |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | EHR | 63.75 - 71.06 | 71.07 - 77.11 | 77.12 - 84.26 | 84.27 - 99.99 | -- | -- | -- | 100 |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | Registry/QCDR | 78.72 - 91.66 | 91.67 - 95.64 | 95.65 - 97.37 | 97.38 - 99.99 | -- | -- | -- | 100 |
| Age Appropriate Screening Colonoscopy | 439 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician . | 440 | Registry/QCDR | 96.91 - 98.95 | 98.96 - 99.87 | 99.88 - 99.99 | -- | -- | -- | -- | 100 |
| Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | 441 | Registry/QCDR | 32.40 - 37.13 | 37.14 - 40.16 | 40.17 - 44.03 | 44.04 - 47.77 | 47.78 - 50.61 | 50.62 - 54.35 | 54.36 - 58.25 | >= 58.26 |
| Persistence of Beta-Blocker Treatment After a Heart Attack | 442 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Non-Recommended Cervical Cancer Screening in Adolescent Females | 443 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Medication Management for People with Asthma | 444 | Registry/QCDR | 91.67 - 95.99 | 96.00 - 97.77 | 97.78 - 98.43 | 98.44 - 99.99 | -- | -- | -- | 100 |
| Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | 445 | Registry/QCDR | 3.90 - 3.17 | 3.16 - 2.69 | 2.68 - 2.25 | 2.24 - 1.73 | 1.72 - 1.23 | 1.22 - 0.01 | -- | 0 |
| Operative Mortality Stratified by the Five STS-EACTS Mortality Categories | 446 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Work Up Prior to Endometrial Ablation | 448 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies | 449 | Registry/QCDR | 95.71 - 98.52 | 98.53 - 99.99 | -- | -- | -- | -- | -- | 100 |
| Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy | 450 | Registry/QCDR | 90.00 - 90.90 | 90.91 - 93.54 | 93.55 - 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 Therapy | 451 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) 4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | 452 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion Receiving Chemotherapy in the Last 14 Days of Life | 453 | Registry/QCDR | 15.00 - 10.43 | 10.42 - 9.19 | 9.18 - 8.00 | 7.99 - 7.36 | 7.35 - 7.04 | 7.03 - 2.39 | 2.38 - 0.01 | 0 |
| Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life | 454 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life | 455 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion Not Admitted To Hospice | 456 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Proportion Admitted to Hospice for less than 3 days | 457 | Registry/QCDR | 15.38 - 15.01 | 15.00 - 13.52 | 13.51 - 11.11 | 11.10 - 9.65 | 9.64 - 6.46 | 6.45 - 0.01 | -- | 0 |
| Average Change in Back Pain following Lumbar Discectomy / Laminotomy | 459 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Average Change in Back Pain following Lumbar Fusion | 460 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy | 461 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | 462 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |
| Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | 463 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use | 464 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and.Interrogation of Ovarian Arteries | 465 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Developmental Screening in the First Three Years of Life | 467 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | 468 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Average Change in Functional Status Following Lumbar Fusion Surgery | 469 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Average Change In Functional Status Following Total Knee Replacement Surgery | 470 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery | 471 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | 472 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |
| Average Change in Leg Pain Following Lumbar Fusion Surgery | 473 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| Zoster (Shingles) Vaccination | 474 | Registry/QCDR | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Screening | 475 | EHR | -- | -- | -- | -- | -- | -- | -- | -- |