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 2020, 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 2018 that was submitted to the Quality Payment Program (QPP) in 2018. *MIPS CQMs are measures submitted using registry rules.
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 (example: Measure 1). An Excel version of the 2020 MIPS Quality Historical Benchmarks can be found here.
*Measures marked in blue (example: Measure 130) can only earn a maximum score of 7 points. There are 61 Measures that meet this description. 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 | Collection Type | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 |
---|---|---|---|---|---|---|---|---|---|---|
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | MIPS CQM | 79.99 - 70.01 | 70 - 60.01 | 60 - 50.01 | 50 - 40.01 | 40 - 30.01 | 30 - 20.01 | 19 - 10.01 | <= 10 |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | eCQM | <= 99.46 | 99.45 - 92.62 | 92.61 - 74.48 | 74.47 - 59.09 | 59.08 - 46.85 | 46.84 - 37.89 | 37.88 - 31.41 | <=31.4 |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | Medicare Part B Claims | 79.99 - 70.01 | 70 - 60.01 | 60 - 50.01 | 50 - 40.01 | 40 - 30.01 | 30 - 20.01 | 19 - 10.01 | <= 10 |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 5 | eCQM | 21.9 - 59.57 | 59.58 - 71.5 | 71.51 - 80.47 | 80.48 - 87.86 | 87.87 - 95.22 | 95.23 - 99.99 | -- | 100 |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 5 | MIPS CQM | 45.19 - 68.5 | 68.51 - 82.34 | 82.35 - 94.34 | 94.35 - 99.99 | -- | -- | -- | 100 |
Coronary Artery Disease (CAD): Antiplatelet Therapy | 6 | MIPS CQM | 11.82 - 74.75 | 74.76 - 86.37 | 86.38 - 93.74 | 93.75 - 98.62 | 98.63 - 99.99 | -- | -- | 100 |
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 7 | eCQM | 37.83 - 70.77 | 70.78 - 80.45 | 80.46 - 86.72 | 86.73 - 91.65 | 91.66 - 95.37 | 95.38 - 97.12 | 97.13 - 99.99 | 100 |
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 7 | MIPS CQM | 60.6 - 82.74 | 82.75 - 89.34 | 89.35 - 94.18 | 94.19 - 97.7 | 97.71 - 99.99 | -- | -- | 100 |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | eCQM | 27.53 - 69.99 | 70 - 81.58 | 81.59 - 89.54 | 89.55 - 94.32 | 94.33 - 97.21 | 97.22 - 99.99 | -- | 100 |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | MIPS CQM | 61.82 - 85.7 | 85.71 - 92.74 | 92.75 - 97.23 | 97.24 - 99.99 | 100 | |||
Anti-Depressant Medication Management | 9 | eCQM | 2.55 - 18.4 | 18.41 - 32.53 | 32.54 - 49.34 | 49.35 - 64.59 | 64.6 - 90.11 | 90.12 - 93.07 | 93.08 - 98.96 | >=98.97 |
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | Medicare Part B Claims | 52.58 - 97.35 | 97.36 - 99.99 | -- | -- | 100 | |||
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | eCQM | 2.93 - 66.65 | 66.66 - 84.72 | 84.73 - 93.9 | 93.91 - 98.25 | 98.26 - 99.69 | 99.7 - 99.99 | -- | 100 |
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | MIPS CQM | 28.48 - 84.48 | 84.49 - 96.96 | 96.97 - 99.99 | -- | 100 | |||
Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | Medicare Part B Claims | 27.65 - 92.46 | 92.47 - 99.99 | -- | -- | 100 | |||
Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | MIPS CQM | 3.45 - 60.77 | 60.78 - 86.91 | 86.92 - 96.92 | 96.93 - 99.9 | 99.91 - 100 | |||
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | eCQM | 2.79 - 35.53 | 35.54 - 65.4 | 65.41 - 86.49 | 86.5 - 96.65 | 96.66 - 99.87 | 99.88 - 99.99 | -- | 100 |
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | MIPS CQM | 3.12 - 38.76 | 38.77 - 82.7 | 82.71 - 98.63 | 98.64 - 99.99 | 100 | |||
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second-Generation Cephalosporin | 21 | Medicare Part B Claims | 6.46 - 94.6 | 94.61 - 99.99 | -- | -- | 100 | |||
Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second-Generation Cephalosporin | 21 | MIPS CQM | 0.43 - 57.08 | 57.09 - 97.53 | 97.54 - 99.99 | -- | 100 | |||
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | Medicare Part B Claims | 2.92 - 98.63 | 98.64 - 99.99 | -- | -- | 100 | |||
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | MIPS CQM | 0.95 - 79.83 | 79.84 - 98.51 | 98.52 - 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 | Medicare Part B Claims | 3.74 - 61.49 | 61.5 - 92.14 | 92.15 - 99.34 | 99.35 - 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 | MIPS CQM | 2.48 - 12.88 | 12.89 - 45.44 | 45.45 - 76.96 | 76.97 - 98.44 | 98.45 - 99.99 | -- | -- | 100 |
Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | Medicare Part B Claims | 3.19 - 23.84 | 23.85 - 41.8 | 41.81 - 56.96 | 56.97 - 74.39 | 74.4 - 93.49 | 93.5 - 99.37 | 99.38 - 99.99 | 100 |
Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | MIPS CQM | 0.28 - 3 | 3.01 - 16.2 | 16.21 - 48.65 | 48.66 - 76.99 | 77 - 94.42 | 94.43 - 99.53 | 99.54 - 99.99 | 100 |
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | 44 | MIPS CQM | 58.73 - 91.73 | 91.74 - 97.55 | 97.56 - 99.99 | -- | 100 | |||
Advance Care Plan | 47 | Medicare Part B Claims | 0.65 - 18.17 | 18.18 - 74.86 | 74.87 - 98.73 | 98.74 - 99.99 | 100 | |||
Advance Care Plan | 47 | MIPS CQM | 0.14 - 4.07 | 4.08 - 36.14 | 36.15 - 82.83 | 82.84 - 98.27 | 98.28 - 99.99 | -- | -- | 100 |
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | Medicare Part B Claims | 0.33 - 1.28 | 1.29 - 5.02 | 5.03 - 98.41 | 98.42 - 99.99 | 100 | |||
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | MIPS CQM | 0.43 - 4.19 | 4.2 - 28.34 | 28.35 - 79.24 | 79.25 - 99.12 | 99.13 - 99.99 | -- | -- | 100 |
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | Medicare Part B Claims | 19.04 - 65.53 | 65.54 - 96.76 | 96.77 - 99.99 | -- | 100 | |||
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | MIPS CQM | 3.56 - 25.64 | 25.65 - 54.01 | 54.02 - 79.15 | 79.16 - 96.28 | 96.29 - 99.99 | -- | -- | 100 |
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | Medicare Part B Claims | 44.62 - 93.26 | 93.27 - 99.99 | -- | -- | 100 | |||
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | MIPS CQM | 36.47 - 62.49 | 62.5 - 79.3 | 79.31 - 97.49 | 97.5 - 99.99 | 100 | |||
Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | eCQM | 25.66 - 75.93 | 75.94 - 86.79 | 86.8 - 93.39 | 93.4 - 97.04 | 97.05 - 99.99 | -- | -- | 100 |
Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | MIPS CQM | 59.39 - 89.07 | 89.08 - 94.61 | 94.62 - 98.71 | 98.72 - 99.99 | 100 | |||
Appropriate Testing for Children with Pharyngitis | 66 | eCQM | 0.51 - 17.69 | 17.7 - 53.71 | 53.72 - 77.03 | 77.04 - 87.68 | 87.69 - 93.53 | 93.54 - 95.82 | 95.83 - 99.99 | 100 |
Appropriate Testing for Children with Pharyngitis | 66 | MIPS CQM | 19.27 - 56.16 | 56.17 - 69.59 | 69.6 - 81.97 | 81.98 - 91.38 | 91.39 - 95.99 | 96 - 98.17 | 98.18 - 99.99 | 100 |
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | 67 | MIPS CQM | 3.67 - 8.57 | 8.58 - 23.25 | 23.26 - 47.49 | 47.5 - 99.77 | 99.78 - 99.99 | -- | -- | 100 |
Hematology: Multiple Myeloma: Treatment with Bisphosphonates | 69 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | 70 | MIPS CQM | 2.82 - 6.96 | 6.97 - 10.7 | 10.71 - 45.44 | 45.45 - 98.74 | 98.75 - 99.99 | -- | -- | 100 |
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 76 | Medicare Part B Claims | 12.38 - 91.82 | 91.83 - 99.99 | -- | -- | 100 | |||
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 76 | MIPS CQM | 20.21 - 89.62 | 89.63 - 97.91 | 97.92 - 99.99 | -- | 100 | |||
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | 93 | Medicare Part B Claims | 18.37 - 94.81 | 94.82 - 99.99 | -- | -- | 100 | |||
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | 93 | MIPS CQM | 41.46 - 73.9 | 73.91 - 86.94 | 86.95 - 95.82 | 95.83 - 99.99 | -- | -- | -- | 100 |
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- |
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | MIPS CQM | 41.44 - 92.48 | 92.49 - 99.99 | -- | -- | -- | -- | -- | 100 |
Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | 104 | MIPS CQM | 25.51 - 61.5 | 61.51 - 92.34 | 92.35 - 98.47 | 98.48 - 99.99 | -- | -- | -- | 100 |
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 107 | eCQM | 0.05 - 0.74 | 0.75 - 5.18 | 5.19 - 30.29 | 30.3 - 72.9 | 72.91 - 96.13 | 96.14 - 99.11 | 99.12 - 99.99 | 100 |
Preventive Care and Screening: Influenza Immunization | 110 | Medicare Part B Claims | 1.1 - 16.14 | 16.15 - 34.76 | 34.77 - 72.83 | 72.84 - 98.82 | 98.83 - 99.99 | -- | -- | 100 |
Preventive Care and Screening: Influenza Immunization | 110 | eCQM | 0.11 - 3.34 | 3.35 - 16.95 | 16.96 - 36.49 | 36.5 - 58.4 | 58.41 - 81.09 | 81.1 - 92.41 | 92.42 - 99.99 | 100 |
Preventive Care and Screening: Influenza Immunization | 110 | MIPS CQM | 0.21 - 11.43 | 11.44 - 32.82 | 32.83 - 61.63 | 61.64 - 88.07 | 88.08 - 99.43 | 99.44 - 99.99 | -- | 100 |
Pneumococcal Vaccination Status for Older Adults | 111 | Medicare Part B Claims | 1.05 - 40.69 | 40.7 - 61.56 | 61.57 - 81.1 | 81.11 - 95.37 | 95.38 - 99.99 | -- | -- | 100 |
Pneumococcal Vaccination Status for Older Adults | 111 | eCQM | 0.15 - 4.44 | 4.45 - 24.15 | 24.16 - 52.06 | 52.07 - 75.22 | 75.23 - 88.81 | 88.82 - 95.03 | 95.04 - 99.99 | 100 |
Pneumococcal Vaccination Status for Older Adults | 111 | MIPS CQM | 0.35 - 13.78 | 13.79 - 43.43 | 43.44 - 68.79 | 68.8 - 82.12 | 82.13 - 93.74 | 93.75 - 99.37 | 99.38 - 99.99 | 100 |
Breast Cancer Screening | 112 | Medicare Part B Claims | 3.12 - 28.63 | 28.64 - 57.13 | 57.14 - 75.93 | 75.94 - 94.96 | 94.97 - 99.99 | -- | -- | 100 |
Breast Cancer Screening | 112 | eCQM | 0.28 - 7.3 | 7.31 - 27.28 | 27.29 - 51.55 | 51.56 - 69.35 | 69.36 - 81.47 | 81.48 - 88.26 | 88.27 - 98.54 | >=98.55 |
Breast Cancer Screening | 112 | MIPS CQM | 0.43 - 7.55 | 7.56 - 27.87 | 27.88 - 55.69 | 55.7 - 77.55 | 77.56 - 92.63 | 92.64 - 99.99 | -- | 100 |
Colorectal Cancer Screening | 113 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Colorectal Cancer Screening | 113 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Colorectal Cancer Screening | 113 | eCQM | 0.13 - 2.58 | 2.59 - 19.33 | 19.34 - 45.63 | 45.64 - 70 | 70.01 - 84.49 | 84.5 - 90.81 | 90.82 - 99.38 | >=99.39 |
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | 116 | MIPS CQM | 6.61 - 37.49 | 37.5 - 55.3 | 55.31 - 81.48 | 81.49 - 98.71 | 98.72 - 99.99 | -- | -- | 100 |
Diabetes: Eye Exam | 117 | Medicare Part B Claims | 3.32 - 25.79 | 25.8 - 91.04 | 91.05 - 99.99 | -- | 100 | |||
Diabetes: Eye Exam | 117 | eCQM | 0.6 - 6.83 | 6.84 - 21.2 | 21.21 - 49.99 | 50 - 97.37 | 97.38 - 99.84 | 99.85 - 99.99 | -- | 100 |
Diabetes: Eye Exam | 117 | MIPS CQM | 0.61 - 23.29 | 23.3 - 80.68 | 80.69 - 97.83 | 97.84 - 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 | MIPS CQM | 34.59 - 71.41 | 71.42 - 77.79 | 77.8 - 84.1 | 84.11 - 89.81 | 89.82 - 97.46 | 97.47 - 99.99 | -- | 100 |
Diabetes: Medical Attention for Nephropathy | 119 | eCQM | 4.17 - 53.56 | 53.57 - 71.41 | 71.42 - 83.46 | 83.47 - 92 | 92.01 - 97.94 | 97.95 - 99.63 | 99.64 - 99.99 | 100 |
Diabetes: Medical Attention for Nephropathy | 119 | MIPS CQM | 5.77 - 57.86 | 57.87 - 77.14 | 77.15 - 87.32 | 87.33 - 98.18 | 98.19 - 99.99 | -- | -- | 100 |
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation | 126 | MIPS CQM | 0.58 - 26.79 | 26.8 - 66.61 | 66.62 - 91.69 | 91.7 - 99.99 | -- | -- | -- | 100 |
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear | 127 | MIPS CQM | 0.48 - 22.58 | 22.59 - 58.66 | 58.67 - 89.92 | 89.93 - 99.99 | -- | -- | -- | 100 |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Medicare Part B Claims | 15.33 - 32.59 | 32.6 - 64.33 | 64.34 - 99.07 | 99.08 - 99.99 | 100 | |||
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | eCQM | 0.42 - 17.47 | 17.48 - 23.88 | 23.89 - 37.38 | 37.39 - 73.96 | 73.97 - 94.14 | 94.15 - 98.35 | 98.36 - 99.99 | 100 |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | MIPS CQM | 4.22 - 22.9 | 22.91 - 40.99 | 41 - 83.85 | 83.86 - 98.35 | 98.36 - 99.99 | -- | -- | 100 |
Documentation of Current Medications in the Medical Record | 130 | Medicare Part B Claims | 13.26 - 93.38 | 93.39 - 99.32 | 99.33 - 99.99 | -- | 100 | |||
Documentation of Current Medications in the Medical Record | 130 | eCQM | 6.46 - 66.01 | 66.02 - 88.81 | 88.82 - 97.34 | 97.35 - 99.68 | 99.69 - 100 | |||
Documentation of Current Medications in the Medical Record | 130 | MIPS CQM | 3.07 - 43.67 | 43.68 - 94.64 | 94.65 - 99.68 | 99.69 - 99.99 | 100 | |||
Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | Medicare Part B Claims | 0.17 - 0.88 | 0.89 - 45.49 | 45.5 - 99.54 | 99.55 - 99.99 | 100 | |||
Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | eCQM | 0.08 - 1.82 | 1.83 - 8.03 | 8.04 - 26.73 | 26.74 - 65.2 | 65.21 - 88.6 | 88.61 - 95.65 | 95.66 - 99.99 | 100 |
Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | MIPS CQM | 0.04 - 2.82 | 2.83 - 27.58 | 27.59 - 74.39 | 74.4 - 96.18 | 96.19 - 99.99 | -- | -- | 100 |
Melanoma: Continuity of Care - Recall System | 137 | MIPS CQM | 3.95 - 67.31 | 67.32 - 95.29 | 95.3 - 99.99 | -- | -- | -- | -- | 100 |
Melanoma: Coordination of Care | 138 | MIPS CQM | 2.13 - 25.6 | 25.61 - 72.16 | 72.17 - 99.99 | -- | -- | -- | -- | 100 |
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Medicare Part B Claims | 37.12 - 96.6 | 96.61 - 99.99 | -- | -- | -- | -- | -- | 100 |
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | MIPS CQM | 0.29 - 9.15 | 9.16 - 17.45 | 17.46 - 26.65 | 26.66 - 82.02 | 82.03 - 99.96 | 99.97 - 99.99 | -- | 100 |
Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | eCQM | 2.27 - 47.97 | 47.98 - 84.62 | 84.63 - 95.94 | 95.95 - 99.05 | 99.06 - 100 | |||
Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | MIPS CQM | 4.15 - 67.44 | 67.45 - 93.08 | 93.09 - 99.52 | 99.53 - 99.99 | 100 | |||
Oncology: Medical and Radiation - Plan of Care for Moderate to Severe Pain | 144 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | 145 | Medicare Part B Claims | 4.25 - 58.75 | 58.76 - 91.16 | 91.17 - 98.6 | 98.61 - 99.99 | 100 | |||
Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy | 145 | MIPS CQM | 3.3 - 47.44 | 47.45 - 86.44 | 86.45 - 98.56 | 98.57 - 99.99 | 100 | |||
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | 146 | Medicare Part B Claims | 4.15 - 0.5 | 0.49 - 0.19 | 0.18 - 0.01 | -- | 0 | |||
Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | 146 | MIPS CQM | 5.57 - 0.66 | 0.65 - 0.25 | 0.24 - 0.11 | 0.1 - 0.04 | 0.03 - 0 | |||
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Medicare Part B Claims | 12.11 - 61.89 | 61.9 - 92.29 | 92.3 - 99.99 | -- | 100 | |||
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | MIPS CQM | 29.25 - 77.36 | 77.37 - 95.22 | 95.23 - 99.99 | -- | 100 | |||
Falls: Risk Assessment | 154 | Medicare Part B Claims | 7.43 - 89.14 | 89.15 - 99.99 | -- | -- | 100 | |||
Falls: Risk Assessment | 154 | MIPS CQM | 3.33 - 31.16 | 31.17 - 78.37 | 78.38 - 98.5 | 98.51 - 99.99 | 100 | |||
Falls: Plan of Care | 155 | Medicare Part B Claims | 1.4 - 28.63 | 28.64 - 99.99 | -- | -- | 100 | |||
Falls: Plan of Care | 155 | MIPS CQM | 1.94 - 26.71 | 26.72 - 70.1 | 70.11 - 94.78 | 94.79 - 99.99 | -- | -- | -- | 100 |
Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | MIPS CQM | 31.14 - 13.56 | 13.55 - 11.36 | 11.35 - 8.72 | 8.71 - 6.8 | 6.79 - 5.83 | 5.82 - 4.7 | 4.69 - 3.94 | <= 3.93 |
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | MIPS CQM | 7.36 - 3.79 | 3.78 - 2.94 | 2.93 - 2.27 | 2.26 - 1.81 | 1.8 - 0 | |||
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | MIPS CQM | 10.93 - 5.93 | 5.92 - 4.08 | 4.07 - 3.24 | 3.23 - 2.31 | 2.3 - 0 | |||
Rheumatoid Arthritis (RA): Tuberculosis Screening | 176 | MIPS CQM | 2.04 - 27.93 | 27.94 - 52.79 | 52.8 - 89.14 | 89.15 - 99.99 | -- | -- | -- | 100 |
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | MIPS CQM | 3.05 - 45.46 | 45.47 - 82.22 | 82.23 - 95.56 | 95.57 - 99.99 | 100 | |||
Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | MIPS CQM | 2.92 - 40.89 | 40.9 - 68.23 | 68.24 - 87.2 | 87.21 - 98.91 | 98.92 - 99.99 | -- | -- | 100 |
Elder Maltreatment Screen and Follow-Up Plan | 181 | Medicare Part B Claims | 0.25 - 12.19 | 12.2 - 99.48 | 99.49 - 99.99 | -- | 100 | |||
Elder Maltreatment Screen and Follow-Up Plan | 181 | MIPS CQM | 0.56 - 27.74 | 27.75 - 67.74 | 67.75 - 92.05 | 92.06 - 99.99 | -- | -- | -- | 100 |
Functional Outcome Assessment | 182 | Medicare Part B Claims | 0.21 - 88.9 | 88.91 - 99.93 | 99.94 - 99.99 | -- | 100 | |||
Functional Outcome Assessment | 182 | MIPS CQM | 0.18 - 1.38 | 1.39 - 5.66 | 5.67 - 87.12 | 87.13 - 99.66 | 99.67 - 99.99 | -- | -- | 100 |
Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use | 185 | MIPS CQM | 1.6 - 27.26 | 27.27 - 71.75 | 71.76 - 98.03 | 98.04 - 99.99 | 100 | |||
Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | MIPS CQM | 11.43 - 53.11 | 53.12 - 79.24 | 79.25 - 97.28 | 97.29 - 99.99 | 100 | |||
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | eCQM | 11.89 - 66.86 | 66.87 - 87.17 | 87.18 - 96.14 | 96.15 - 98.86 | 98.87 - 99.99 | -- | -- | 100 |
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | MIPS CQM | 55.45 - 87.71 | 87.72 - 95.06 | 95.07 - 98.9 | 98.91 - 99.99 | 100 | |||
Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Medicare Part B Claims | 39.7 - 90.55 | 90.56 - 98.48 | 98.49 - 99.99 | -- | 100 | |||
Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | MIPS CQM | 48.4 - 93.51 | 93.52 - 98.97 | 98.98 - 99.99 | -- | 100 | |||
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Knee Impairments | 217 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Hip Impairments | 218 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | 219 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Low Back Impairments | 220 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Shoulder Impairments | 221 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Radiology: Reminder System for Screening Mammograms | 225 | Medicare Part B Claims | 3.45 - 99.16 | 99.17 - 99.99 | -- | -- | -- | -- | -- | 100 |
Radiology: Reminder System for Screening Mammograms | 225 | MIPS CQM | 29.83 - 99.99 | -- | -- | -- | -- | -- | -- | 100 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Medicare Part B Claims | 66.66 - 95.85 | 95.86 - 99.29 | 99.3 - 99.99 | -- | -- | -- | -- | 100 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | eCQM | 0.93 - 7.26 | 7.27 - 24.15 | 24.16 - 73.97 | 73.98 - 90.28 | 90.29 - 97.1 | 97.11 - 99.99 | -- | 100 |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | MIPS CQM | 1.88 - 10.45 | 10.46 - 25.48 | 25.49 - 65.69 | 65.7 - 97.66 | 97.67 - 99.99 | -- | -- | 100 |
Controlling High Blood Pressure | 236 | Medicare Part B Claims | 20 - 29.99 | 30 - 39.99 | 40 - 49.99 | 50 - 59.99 | 60 - 69.99 | 70 - 79.99 | 80 - 89.99 | >= 90 |
Controlling High Blood Pressure | 236 | MIPS CQM | 20 - 29.99 | 30 - 39.99 | 40 - 49.99 | 50 - 59.99 | 60 - 69.99 | 70 - 79.99 | 80 - 89.99 | >= 90 |
Controlling High Blood Pressure | 236 | eCQM | 20 - 29.99 | 30 - 39.99 | 40 - 49.99 | 50 - 59.99 | 60 - 69.99 | 70 - 79.99 | 80 - 89.99 | >= 90 |
Use of High-Risk Medications in the Elderly | 238 | MIPS CQM | 27.17 - 13.48 | 13.47 - 8.52 | 8.51 - 2.18 | 2.17 - 0.34 | 0.33 - 0 | |||
Use of High-Risk Medications in the Elderly | 238 | eCQM | 32.77- 16.99 | 16.98 - 11.49 | 11.48 - 4.4 | 4.39 - 0.58 | 0.57 - 0 | |||
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 239 | eCQM | 0.46 - 21.78 | 21.79 - 29.34 | 29.35 - 33.32 | 33.33 - 43.69 | 43.7 - 71.49 | 71.5 - 85.53 | 85.54 - 99.39 | >=99.4 |
Childhood Immunization Status | 240 | eCQM | 0.95 - 5.25 | 5.26 - 15.09 | 15.1 - 29.41 | 29.42 - 40.61 | 40.62 - 53.55 | 53.56 - 60.14 | 60.15 - 75.58 | >=75.59 |
Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | MIPS CQM | 0.5 - 2.62 | 2.63 - 7.27 | 7.28 - 20.74 | 20.75 - 42.9 | 42.91 - 71.81 | 71.82 - 88.16 | 88.17 - 99.99 | 100 |
Barrett's Esophagus | 249 | Medicare Part B Claims | 97.2 - 99.99 | -- | -- | -- | 100 | |||
Barrett's Esophagus | 249 | MIPS CQM | 71.31 - 99.84 | 99.85 - 99.99 | -- | -- | 100 | |||
Radical Prostatectomy Pathology Reporting | 250 | Medicare Part B Claims | 98.1 - 99.99 | -- | -- | -- | 100 | |||
Radical Prostatectomy Pathology Reporting | 250 | MIPS CQM | 98.78 - 99.99 | -- | -- | -- | 100 | |||
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | MIPS CQM | 57.55 - 80.39 | 80.4 - 90.61 | 90.62 - 96.28 | 96.29 - 99.99 | -- | -- | -- | 100 |
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 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | 259 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | MIPS CQM | 29.83 - 85.11 | 85.12 - 88.16 | 88.17 - 91.93 | 91.94 - 97.12 | 97.13 - 99.99 | -- | -- | 100 |
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | MIPS CQM | 89.01 - 95.33 | 95.34 - 98.59 | 98.6 - 99.99 | -- | 100 | |||
Biopsy Follow-Up | 265 | MIPS CQM | 0.66 - 25.36 | 25.37 - 82.3 | 82.31 - 99.78 | 99.79 - 99.99 | 100 | |||
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | MIPS CQM | 1.95 - 14.67 | 14.68 - 28.83 | 28.84 - 64.69 | 64.7 - 95.44 | 95.45 - 99.99 | -- | -- | 100 |
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Sleep Apnea: Severity Assessment at Initial Diagnosis | 277 | MIPS CQM | 0.36 - 5.68 | 5.69 - 38.82 | 38.83 - 90.61 | 90.62 - 99.99 | -- | -- | -- | 100 |
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | 279 | MIPS CQM | 25.5 - 50.29 | 50.3 - 80.61 | 80.62 - 98.66 | 98.67 - 99.99 | 100 | |||
Dementia: Cognitive Assessment | 281 | eCQM | 0.51 - 3.56 | 3.57 - 10.27 | 10.28 - 43.86 | 43.87 - 87.33 | 87.34 - 98.51 | 98.52 - 99.99 | -- | 100 |
Dementia: Functional Status Assessment | 282 | MIPS CQM | 0.85 - 28.15 | 28.16 - 70.57 | 70.58 - 96.65 | 96.66 - 99.99 | 100 | |||
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | 283 | MIPS CQM | 7.78 - 52.44 | 52.45 - 89.75 | 89.76 - 99.76 | 99.77 - 99.99 | 100 | |||
Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | 286 | MIPS CQM | 5.2 - 19.55 | 19.56 - 56.03 | 56.04 - 98.28 | 98.29 - 99.99 | 100 | |||
Dementia: Education and Support of Caregivers for Patients with Dementia | 288 | MIPS CQM | 3.48 - 15.72 | 15.73 - 44.87 | 44.88 - 86.83 | 86.84 - 99.99 | -- | -- | -- | 100 |
Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease | 290 | MIPS CQM | 3.5 - 9.37 | 9.38 - 22.94 | 22.95 - 51.84 | 51.85 - 99.99 | -- | -- | -- | 100 |
Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease | 291 | MIPS CQM | 1.77 - 10.78 | 10.79 - 56.4 | 56.41 - 99.99 | -- | 100 | |||
Parkinson's Disease: Rehabilitative Therapy Options | 293 | MIPS CQM | 3.7 - 24.61 | 24.62 - 63.32 | 63.33 - 95.64 | 95.65 - 99.99 | 100 | |||
Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | 303 | MIPS CQM | 1.98 - 26.35 | 26.36 - 42.92 | 42.93 - 69.96 | 69.97 - 96.72 | 96.73 - 99.99 | -- | -- | 100 |
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | MIPS CQM | 1.6 - 20.14 | 20.15 - 49.27 | 49.28 - 75.75 | 75.76 - 96.39 | 96.4 - 99.99 | -- | -- | 100 |
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | eCQM | 0.08 - 0.36 | 0.37 - 0.64 | 0.65 - 1.43 | 1.44 - 3.33 | 3.34 - 8.02 | 8.03 - 12.36 | 12.37 - 39.07 | >=39.08 |
Cervical Cancer Screening | 309 | eCQM | 0.27 - 3.41 | 3.42 - 14.37 | 14.38 - 32.08 | 32.09 - 53.86 | 53.87 - 73.98 | 73.99 - 85.35 | 85.36 - 96.91 | >=96.92 |
Chlamydia Screening for Women | 310 | eCQM | 0.91 - 6.88 | 6.89 - 19.03 | 19.04 - 35.12 | 35.13 - 50.59 | 50.6 - 66.53 | 66.54 - 72.12 | 72.13 - 82.47 | >=82.48 |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Medicare Part B Claims | 4.32 - 29.34 | 29.35 - 55.77 | 55.78 - 95.57 | 95.58 - 99.99 | -- | -- | -- | 100 |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | eCQM | 0.23 - 12.24 | 12.25 - 21.9 | 21.91 - 31.4 | 31.41 - 43.4 | 43.41 - 61.52 | 61.53 - 79.17 | 79.18 - 99.99 | 100 |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | MIPS CQM | 0.26 - 16.39 | 16.4 - 33.22 | 33.23 - 53.73 | 53.74 - 91.5 | 91.51 - 99.99 | -- | -- | 100 |
Falls: Screening for Future Fall Risk | 318 | eCQM | 0.04 - 1.38 | 1.39 - 21.67 | 21.68 - 65.26 | 65.27 - 90.35 | 90.36 - 98.15 | 98.16 - 99.5 | 99.51 - 99.99 | 100 |
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Medicare Part B Claims | 17.34 - 86.8 | 86.81 - 95.22 | 95.23 - 99.99 | -- | 100 | |||
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | MIPS CQM | 1.02 - 59.13 | 59.14 - 85.38 | 85.39 - 95.09 | 95.1 - 99.07 | 99.08 - 100 | |||
CAHPS for MIPs Clinician/Group Survey | 321 | Certified Survey Vendor | -- | -- | -- | -- | -- | -- | -- | -- |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients | 322 | MIPS CQM | 65.24 - 5.83 | 5.82 - 0.97 | 0.96 - 0.01 | -- | 0 | |||
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | 323 | MIPS CQM | 77.03 - 4.87 | 4.86 - 0.68 | 0.67 - 0.01 | -- | 0 | |||
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | 324 | MIPS CQM | 55.83 - 30.16 | 30.15 - 20.9 | 20.89 - 2.78 | 2.77 - 0.01 | 0 | |||
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Medicare Part B Claims | 48.19 - 93.12 | 93.13 - 99.99 | -- | -- | 100 | |||
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | MIPS CQM | 22.05 - 68.06 | 68.07 - 79.5 | 79.51 - 95.03 | 95.04 - 99.99 | -- | -- | -- | 100 |
Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | MIPS CQM | 100 - 97.36 | 97.35 - 87.13 | 87.12 - 76.08 | 76.07 - 65.57 | 65.56 - 54.28 | 54.27 - 43.59 | 43.58 - 34.32 | 34.31 - 23.19 |
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | MIPS CQM | 15.68 - 58.19 | 58.2 - 87.82 | 87.83 - 98.07 | 98.08 - 99.99 | 100 | |||
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | 333 | MIPS CQM | 59.37 - 11.85 | 11.84 - 6.36 | 6.35 - 1.82 | 1.81 - 0.01 | 0 | |||
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse) | 335 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Maternity Care: Postpartum Follow-up and Care Coordination | 336 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier | 337 | MIPS CQM | 3.69 - 27.57 | 27.58 - 62.33 | 62.34 - 90.46 | 90.47 - 99.99 | -- | -- | -- | 100 |
HIV Viral Load Suppression | 338 | MIPS CQM | 28.21 - 50.19 | 50.2 - 77.96 | 77.97 - 86.59 | 86.6 - 97.48 | 97.49 - 99.99 | -- | -- | 100 |
HIV Medical Visit Frequency | 340 | MIPS CQM | 9.49 - 40.65 | 40.66 - 51.88 | 51.89 - 70.2 | 70.21 - 92.12 | 92.13 - 99.99 | -- | -- | 100 |
Pain Brought Under Control Within 48 Hours | 342 | MIPS CQM | 34.48 - 86.06 | 86.07 - 99.99 | -- | -- | -- | -- | -- | 100 |
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | 344 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Implantable Cardioverter-Defibrillator (ICD) Complications Rate | 348 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | 350 | MIPS CQM | 22.86 - 89.52 | 89.53 - 99.64 | 99.65 - 99.99 | -- | 100 | |||
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | 351 | MIPS CQM | 8.82 - 92.43 | 92.44 - 99.99 | -- | -- | 100 | |||
Anastomotic Leak Intervention | 354 | MIPS CQM | 90.33 - 20.78 | 20.77 - 8.34 | 8.33 - 3.23 | 3.22 - 0.01 | 0 | |||
Unplanned Reoperation within the 30 Day Postoperative Period | 355 | MIPS CQM | 82.57 - 10.15 | 10.14 - 4.61 | 4.6 -2.22 | 2.21 - 0.36 | 0.35 - 0 | |||
Unplanned Hospital Readmission within 30 Days of Principal Procedure | 356 | MIPS CQM | 68.31 - 9.32 | 9.31 - 6.11 | 6.1 - 3.23 | 3.22 - 0.88 | 0.87 - 0 | |||
Surgical Site Infection (SSI) | 357 | MIPS CQM | 92.4 - 40.46 | 40.45 - 5.53 | 5.52 - 1.67 | 1.66 - 0.01 | 0 | |||
Patient-Centered Surgical Risk Assessment and Communication | 358 | MIPS CQM | 0.32 - 4.82 | 4.83 - 54.81 | 54.82 - 97.35 | 97.36 - 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 | MIPS CQM | 0.3 - 2.66 | 2.67 - 9.8 | 9.81 - 98.89 | 98.9 - 99.99 | 100 | |||
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 364 | MIPS CQM | 1.05 - 54.42 | 54.43 - 75.82 | 75.83 - 91.79 | 91.8 - 99.99 | -- | -- | -- | 100 |
Follow-Up Care for Children Prescribed ADHD Medication (ADD) | 366 | eCQM | 1.74 - 10.43 | 10.44 - 15.28 | 15.29 - 26.4 | 26.41 - 35.44 | 35.45 - 49.47 | 49.48 - 74.41 | 74.42 - 90.53 | >=90.54 |
Depression Remission at Twelve Months | 370 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Depression Remission at Twelve Months | 370 | eCQM | 0.54 - 1.41 | 1.42 - 2.93 | 2.94 - 6.99 | 7 - 16.78 | 16.79 - 31.74 | 31.75 - 48.4 | 48.41 - 64.91 | >=64.92 |
Closing the Referral Loop: Receipt of Specialist Report | 374 | eCQM | 0.23 - 2.62 | 2.63 - 10.46 | 10.47 - 37.69 | 37.7 - 68.19 | 68.2 - 90.18 | 90.19 - 97.42 | 97.43 - 99.99 | 100 |
Closing the Referral Loop: Receipt of Specialist Report | 374 | MIPS CQM | 1.13 - 5.89 | 5.9 - 51.75 | 51.76 - 96.19 | 96.2 - 99.99 | -- | -- | -- | 100 |
Functional Status Assessment for Total Knee Replacement | 375 | eCQM | 0.33 - 1.48 | 1.49 - 3.11 | 3.12 - 14.99 | 15 - 45.63 | 45.64 - 75.13 | 75.14 - 85.54 | 85.55 - 98.15 | >=98.16 |
Functional Status Assessment for Total Hip Replacement | 376 | eCQM | 0.55 - 1.64 | 1.65 - 4.99 | 5 - 17.76 | 17.77 - 39.99 | 40 - 68.99 | 69 - 83.06 | 83.07 - 91.16 | >=91.17 |
Functional Status Assessments for Congestive Heart Failure | 377 | eCQM | 0.04 - 0.8 | 0.81 - 1.41 | 1.42 - 4.1 | 4.11 - 8.55 | 8.56 - 16.31 | 16.32 - 21.54 | 21.55 - 55.45 | >=55.46 |
Children Who Have Dental Decay or Cavities | 378 | eCQM | 5.57 - 2.19 | 2.18 - 1.37 | 1.36 - 0.36 | 0.35 - 0.01 | 0 | |||
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 379 | eCQM | 0 - 0.05 | 0.06 - 0.3 | 0.31 - 2.4 | 2.41 - 5.53 | 5.54 - 11.22 | 11.23 - 18.21 | 18.22 - 25.52 | >=25.53 |
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | eCQM | 0.22 - 1.48 | 1.49 - 9.85 | 9.86 - 27.95 | 27.96 - 53.47 | 53.48 - 83.41 | 83.42 - 93.96 | 93.97 - 99.99 | 100 |
Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | MIPS CQM | 8.74 - 39.32 | 39.33 - 79.43 | 79.44 - 98.83 | 98.84 - 99.99 | -- | -- | -- | 100 |
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | MIPS CQM | 67.73 - 91.45 | 91.46 - 99.99 | -- | -- | -- | -- | -- | 100 |
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | 386 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | 387 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Cataract Surgery: Difference Between Planned and Final Refraction | 389 | MIPS CQM | 0.1 - 0.44 | 0.45 - 0.81 | 0.82 - 1.48 | 1.49 - 3.21 | 3.22 - 93.74 | 93.75 - 99.99 | -- | 100 |
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | 390 | MIPS CQM | 4.64 - 37.9 | 37.91 - 69.46 | 69.47 - 99.99 | -- | 100 | |||
Follow-Up After Hospitalization for Mental Illness (FUH) | 391 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | 392 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | 393 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Immunizations for Adolescents | 394 | MIPS CQM | 0.55 - 1.99 | 2 - 4.27 | 4.28 - 13.78 | 13.79 - 23.8 | 23.81 - 36.41 | 36.42 - 46.36 | 46.37 - 60.94 | >=60.95 |
Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Medicare Part B Claims | 92.37 - 99.99 | -- | -- | -- | 100 | |||
Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | MIPS CQM | 53.87 - 99.61 | 99.62 - 99.99 | -- | -- | 100 | |||
Lung Cancer Reporting (Resection Specimens) | 396 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Lung Cancer Reporting (Resection Specimens) | 396 | MIPS CQM | 70.78 - 99.99 | -- | -- | -- | 100 | |||
Melanoma Reporting | 397 | Medicare Part B Claims | 96.56 - 99.99 | -- | -- | -- | 100 | |||
Melanoma Reporting | 397 | MIPS CQM | 3.33 - 91.15 | 91.16 - 99.99 | -- | -- | 100 | |||
Optimal Asthma Control | 398 | MIPS CQM | 0.68 - 20.38 | 20.39 - 44.4 | 44.41 - 84.57 | 84.58 - 99.99 | -- | -- | -- | 100 |
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | 400 | MIPS CQM | 0.13 - 0.37 | 0.38 - 1.26 | 1.27 - 3.89 | 3.9 - 46.37 | 46.38 - 87.67 | 87.68 - 99.99 | -- | 100 |
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Tobacco Use and Help with Quitting Among Adolescents | 402 | MIPS CQM | 24.3 - 77.34 | 77.35 - 90.37 | 90.38 - 97.05 | 97.06 - 99.91 | 99.92 - 100 | |||
Anesthesiology Smoking Abstinence | 404 | MIPS CQM | 7.52 - 36.24 | 36.25 - 51.78 | 51.79 - 69.54 | 69.55 - 85.12 | 85.13 - 97.3 | 97.31 - 99.77 | 99.78 - 99.99 | 100 |
Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Medicare Part B Claims | 81.33- 31.57 | 33.56 - 4.88 | 4.87 - 0.01 | -- | -- | -- | -- | 0 |
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | MIPS CQM | 66.08 - 29.91 | 29.9 - 16.92 | 16.91 - 4.53 | 4.52 - 0.01 | 0 | |||
Opioid Therapy Follow-up Evaluation | 408 | MIPS CQM | 0.38 - 29.59 | 29.6 - 74.99 | 75 - 98.9 | 98.91 - 99.99 | 100 | |||
Clinical Outcome Post Endovascular Stroke Treatment | 409 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Psoriasis: Clinical Response to Systemic Medications | 410 | MIPS CQM | 1.81 - 15.02 | 15.03 - 42.9 | 42.91 - 76.71 | 76.72 - 96.6 | 96.61 - 99.99 | -- | -- | 100 |
Documentation of Signed Opioid Treatment Agreement | 412 | MIPS CQM | 0.97 - 40.91 | 40.92 - 76.69 | 76.7 - 99.99 | -- | 100 | |||
Door to Puncture Time for Endovascular Stroke Treatment | 413 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Evaluation or Interview for Risk of Opioid Misuse | 414 | MIPS CQM | 4.64 - 59.54 | 59.55 - 96.32 | 96.33 - 99.99 | -- | 100 | |||
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | MIPS CQM | 34.04 - 58.24 | 58.25 - 72.21 | 72.22 - 93.54 | 93.55 - 99.53 | 99.54 - 99.99 | -- | -- | 100 |
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | MIPS CQM | 65.88 - 44.29 | 44.28 - 40.82 | 40.81 - 30.48 | 30.47 - 15.63 | 15.62 - 2.39 | 2.38 - 0.01 | -- | 0 |
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Osteoporosis Management in Women Who Had a Fracture | 418 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Osteoporosis Management in Women Who Had a Fracture | 418 | MIPS CQM | 0.52 - 2.03 | 2.04 - 3.3 | 3.31 - 9.51 | 9.52 - 39.11 | 39.12 - 89.64 | 89.65 - 99.99 | -- | 100 |
Overuse of Imaging for the Evaluation of Primary Headache | 419 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Overuse of Imaging for the Evaluation of Primary Headache | 419 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | 420 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | 421 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Perioperative Temperature Management | 424 | MIPS CQM | 48.43 - 91.68 | 91.69 - 98.88 | 98.89 - 99.84 | 99.85 - 99.99 | 100 | |||
Photodocumentation of Cecal Intubation | 425 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Photodocumentation of Cecal Intubation | 425 | MIPS CQM | -- | -- | -- | -- | -- | |||
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy | 430 | MIPS CQM | 31.65 - 87.82 | 87.83 - 96.42 | 96.43 - 99.25 | 99.26 - 99.97 | 99.98 - 100 | |||
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | MIPS CQM | 0.22 - 11.37 | 11.38 - 44.87 | 44.88 - 81.56 | 81.57 - 97.16 | 97.17 - 99.99 | -- | -- | 100 |
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | 432 | MIPS CQM | 1.73 - 0.97 | 0.96 - 0.01 | -- | -- | -- | -- | -- | 0 |
Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 433 | MIPS CQM | 1.12 - 1.02 | 1.01 - 0.41 | 0.4 - 0.01 | -- | -- | -- | -- | 0 |
Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair | 434 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | MIPS CQM | 0.78 - 3.54 | 3.55 - 7.78 | 7.79 - 49.07 | 49.08 - 99.99 | -- | -- | -- | 100 |
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Medicare Part B Claims | 2.36 - 90.17 | 90.18 - 98.48 | 98.49 - 99.89 | 99.9 - 99.99 | 100 | |||
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | MIPS CQM | 0.84 - 85.15 | 85.16 - 98.36 | 98.37 - 99.91 | 99.92 - 99.99 | 100 | |||
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Medicare Part B Claims | 3.91 - 3.58 | 3.57 - 2.95 | 2.94 - 2.03 | 2.02 - 0.01 | -- | -- | -- | 0 |
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | MIPS CQM | 19.09 - 9.43 | 9.42 - 6.41 | 6.4 - 0.35 | 0.34 - 0.01 | -- | -- | -- | 0 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | eCQM | 3.54 - 42.19 | 42.2 - 60.55 | 60.56 - 69.82 | 69.83 - 77.12 | 77.13 - 83.5 | 83.51 - 86.2 | 86.21 - 95.54 | >=95.55 |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | MIPS CQM | 32.72 - 64.82 | 64.83 - 76.21 | 76.22 - 91.65 | 91.66 - 99.99 | -- | -- | -- | 100 |
Age Appropriate Screening Colonoscopy | 439 | MIPS CQM | 74.22 - 43.37 | 43.36 - 30.39 | 30.38 - 0.01 | -- | -- | -- | -- | 0 |
Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician | 440 | MIPS CQM | 6.94 - 92.08 | 92.09 - 99.15 | 99.16 - 99.99 | -- | 100 | |||
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | 441 | MIPS CQM | 1.7 - 20.82 | 20.83 - 40.4 | 40.41 - 58.97 | 58.98 - 69 | 69.01 - 77.36 | 77.37 - 81.72 | 81.73 - 87.39 | >=87.4 |
Non-Recommended Cervical Cancer Screening in Adolescent Females | 443 | MIPS CQM | 11.39 - 7.1 | 7.09 - 3.49 | 3.48 - 2.3 | 2.29 - 0.01 | -- | -- | -- | 0 |
Medication Management for People with Asthma | 444 | MIPS CQM | 14.57 - 57.19 | 57.2 - 77.34 | 77.35 - 96.65 | 96.66 - 99.99 | 100 | |||
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | 445 | MIPS CQM | 10.32 - 6.9 | 6.89 - 5.09 | 5.08 - 2.91 | 2.90 - 1.87 | 1.86 - 0.65 | 0.64 - 0.01 | -- | 0 |
Appropriate Workup Prior to Endometrial Ablation | 448 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy | 450 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | 451 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | 452 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better) | 453 | MIPS CQM | 36.53 - 24.01 | 24 - 20.01 | 20 - 16.01 | 16 - 10.01 | 10 - 6.13 | 6.12 - 4.35 | 4.34 - 3.32 | <= 3.31 |
Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better) | 455 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better) | 457 | MIPS CQM | 24.9 - 20.52 | 20.51 - 18.78 | 18.77 - 14.96 | 14.95 - 10.01 | 10 - 5.51 | 5.5 - 3.54 | 3.53 - 2.89 | <= 2.88 |
All-cause Hospital Readmission | 458 | Administrative Claims | -- | -- | -- | -- | -- | -- | -- | -- |
Back Pain After Lumbar Discectomy/Laminectomy | 459 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Back Pain After Lumbar Fusion | 460 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Leg Pain After Lumbar Discectomy/Laminectomy | 461 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy | 462 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- |
Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | 463 | MIPS CQM | 58.58 - 91.17 | 91.18 - 95.69 | 95.7 - 98.56 | 98.57 - 99.99 | -- | -- | -- | 100 |
Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | 464 | MIPS CQM | 70.38 - 80.63 | 80.64 - 88.12 | 88.13 - 94.79 | 94.8 - 98.16 | 98.17 - 99.99 | -- | -- | 100 |
Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | 465 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | 468 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status After Lumbar Fusion | 469 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status After Primary Total Knee Replacement | 470 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status After Lumbar Discectomy/Laminectomy | 471 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture | 472 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- |
Leg Pain After Lumbar Fusion | 473 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
HIV Screening | 475 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- |
International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia | 476 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- |
Multimodal Pain Management | 477 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |
Functional Status Change for Patients with Neck Impairments | 478 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- |