MIPS Measures Relevant to Family Medicine

  1. Quality - 45% of total score:  Report 6 measures, including one Outcome or one high priority measure for 12 months. To earn 1 or 3 points on a measure report at least one eligible case. To earn more than 3 points on a measure report at least 60 percent of eligible cases.  Suggestions for your specialty include but are not limited to the following:

    ID:

    001
    NQF:

    0059
    eMeasure ID:

    CMS122v6
    High Priority:

    Yes

    #001: Diabetes: Hemoglobin A1c Poor Control

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

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

    005
    NQF:

    0081
    eMeasure ID:

    CMS135v6
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

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

    006
    NQF:

    0067
    eMeasure ID:
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel

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

    007
    NQF:

    0070
    eMeasure ID:

    CMS145v6
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy

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

    008
    NQF:

    0083
    eMeasure ID:

    CMS144v6
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

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

    009
    NQF:

    0105
    eMeasure ID:

    CMS128v6
    High Priority:

    No

    #009: Anti-Depressant Medication Management

    Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: 

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

    024
    NQF:

    0045
    eMeasure ID:
    High Priority:

    Yes

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

    Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication

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

    039
    NQF:

    0046
    eMeasure ID:
    High Priority:

    No

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

    Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis

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

    047
    NQF:

    0326
    eMeasure ID:
    High Priority:

    Yes

    #047: Care Plan

    Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

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

    048
    NQF:
    eMeasure ID:
    High Priority:

    No

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

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

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

    050
    NQF:
    eMeasure ID:
    High Priority:

    Yes

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

    Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months

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

    065
    NQF:

    0069
    eMeasure ID:

    CMS154v6
    High Priority:

    Yes

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

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:

    066
    NQF:
    eMeasure ID:

    CMS146v6
    High Priority:

    Yes

    #066: Appropriate Testing for Children with Pharyngitis

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Pediatrics
    • Urgent Care
    ID:

    091
    NQF:

    0653
    eMeasure ID:
    High Priority:

    Yes

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

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:

    093
    NQF:

    0654
    eMeasure ID:
    High Priority:

    Yes

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

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Pediatrics
    • Urgent Care
    ID:

    107
    NQF:

    0104
    eMeasure ID:

    CMS161v6
    High Priority:

    No

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

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

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

    109
    NQF:
    eMeasure ID:
    High Priority:

    Yes

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

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

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

    110
    NQF:

    0041
    eMeasure ID:

    CMS147v7
    High Priority:

    No

    #110: Preventive Care and Screening: Influenza Immunization

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Family Medicine
    • Oncology
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Pediatrics
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    ID:

    111
    NQF:

    0043
    eMeasure ID:

    CMS127v6
    High Priority:

    No

    #111: Pneumococcal Vaccination Status for Older Adults

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

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

    112
    NQF:

    2372
    eMeasure ID:

    CMS125v6
    High Priority:

    No

    #112: Breast Cancer Screening

    Percentage of women 51 - 74 years of age who had a mammogram to screen for breast cancer

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

    113
    NQF:

    0034
    eMeasure ID:

    CMS130v7
    High Priority:

    No

    #113: Colorectal Cancer Screening

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

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

    116
    NQF:

    0058
    eMeasure ID:
    High Priority:

    Yes

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

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Preventive Medicine
    • Urgent Care
    ID:

    117
    NQF:

    0055
    eMeasure ID:

    CMS131v6
    High Priority:

    No

    #117: Diabetes: Eye Exam

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

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

    119
    NQF:

    0062
    eMeasure ID:

    CMS134v6
    High Priority:

    No

    #119: Diabetes: Medical Attention for Nephropathy

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

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

    126
    NQF:

    0417
    eMeasure ID:
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months

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

    128
    NQF:

    0421
    eMeasure ID:

    CMS69v6
    High Priority:

    No

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

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

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

    130
    NQF:

    0419
    eMeasure ID:

    CMS68v7
    High Priority:

    Yes

    #130: Documentation of Current Medications in the Medical Record

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

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

    134
    NQF:

    0418
    eMeasure ID:

    CMS2v7
    High Priority:

    No

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

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

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

    154
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #154: Falls: Risk Assessment

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

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

    155
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    #155: Falls: Plan of Care

    Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

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

    181
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #181: Elder Maltreatment Screen and Follow-Up Plan

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Skilled Nursing Facility
    ID:

    226
    NQF:

    0028
    eMeasure ID:

    CMS138v6
    High Priority:

    No

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

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

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

    236
    NQF:

    0018
    eMeasure ID:

    CMS165v6
    High Priority:

    Yes

    #236: Controlling High Blood Pressure

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

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

    238
    NQF:

    0022
    eMeasure ID:

    CMS156v6
    High Priority:

    Yes

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

    Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.

    1) Percentage of patients who were ordered at least one high-risk medication.
    2) Percentage of patients who were ordered at least two of the same high-risk medication

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

    243
    NQF:

    0643
    eMeasure ID:
    High Priority:

    Yes

    #243: Cardiac Rehabilitation Patient Referral from an Outpatient Setting

    Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program

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

    305
    NQF:

    0004
    eMeasure ID:

    CMS137v6
    High Priority:

    No

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

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

    a. Percentage of patients who initiated treatment within 14 days of the diagnosis.
    b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.

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

    309
    NQF:

    0032
    eMeasure ID:

    CMS124v6
    High Priority:

    No

    #309: Cervical Cancer Screening

    Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

    * Women age 21-64 who had cervical cytology performed every 3 years
    * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

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

    317
    NQF:
    eMeasure ID:

    CMS22v6
    High Priority:

    No

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

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

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

    318
    NQF:

    0101
    eMeasure ID:

    CMS139v6
    High Priority:

    No

    #318: Falls: Screening for Future Fall Risk

    Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Orthopedic Surgery
    • Podiatry
    ID:

    326
    NQF:

    1525
    eMeasure ID:
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period

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

    331
    NQF:
    eMeasure ID:
    High Priority:

    No

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

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

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:

    332
    NQF:
    eMeasure ID:
    High Priority:

    Yes

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

    Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis

    Measure Type
    • Process
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:

    333
    NQF:
    eMeasure ID:
    High Priority:

    Yes

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

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

    Measure Type
    • Efficiency
    Specifications
    Specialty
    • Emergency Medicine
    • Family Medicine
    • Internal Medicine
    • Otolaryngology
    • Urgent Care
    ID:

    337
    NQF:
    eMeasure ID:
    High Priority:

    No

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

    Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test

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

    338
    NQF:

    2082
    eMeasure ID:
    High Priority:

    Yes

    #338: HIV Viral Load Suppression

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

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

    342
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #342: Pain Brought Under Control Within 48 Hours

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

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

    370
    NQF:

    0710
    eMeasure ID:

    CMS159v6
    High Priority:

    Yes

    #370: Depression Remission at Twelve Months

    The percentage of adolescent patients12 to 17 years of age and adult patients18 yem1ars of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date

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

    371
    NQF:

    0712
    eMeasure ID:

    CMS160v6
    High Priority:

    No

    #371: Depression Utilization of the PHQ-9 Tool

    The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter

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

    374
    NQF:
    eMeasure ID:

    CMS50v6
    High Priority:

    Yes

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

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

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

    377
    NQF:
    eMeasure ID:

    CMS90v7
    High Priority:

    Yes

    #377: Functional Status Assessments for Congestive Heart Failure

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

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

    383
    NQF:

    1879
    eMeasure ID:
    High Priority:

    Yes

    #383: Adherence to Antipsychotic Medications For Individuals with Schizophrenia

    Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

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

    387
    NQF:

    3060
    eMeasure ID:
    High Priority:

    No

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

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

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

    394
    NQF:

    1407
    eMeasure ID:
    High Priority:

    No

    #394: Immunizations for Adolescents

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

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

    398
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #398: Optimal Asthma Control

    Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation

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

    400
    NQF:

    3059
    eMeasure ID:
    High Priority:

    No

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

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

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

    401
    NQF:
    eMeasure ID:
    High Priority:

    No

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

    Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission period

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

    402
    NQF:
    eMeasure ID:
    High Priority:

    No

    #402: Tobacco Use and Help with Quitting Among Adolescents

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

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

    408
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #408: Opioid Therapy Follow-up Evaluation

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

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

    412
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #412: Documentation of Signed Opioid Treatment Agreement

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

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

    414
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    #414: Evaluation or Interview for Risk of Opioid Misuse

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

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

    418
    NQF:

    0053
    eMeasure ID:
    High Priority:

    No

    #418: Osteoporosis Management in Women Who Had a Fracture

    The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture

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

    431
    NQF:

    2152
    eMeasure ID:
    High Priority:

    No

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

    Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

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

    438
    NQF:
    eMeasure ID:

    CMS347v1
    High Priority:

    No

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

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

    • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
    • Adults aged ≥ 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
    • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

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

    441
    NQF:
    eMeasure ID:
    High Priority:

    Yes

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

    The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:

    • Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND
    • Most recent tobacco status is Tobacco Free -- AND
    • Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND
    • Statin Use Unless Contraindicated

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

    442
    NQF:

    0071
    eMeasure ID:
    High Priority:

    No

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

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

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

    443
    NQF:
    eMeasure ID:
    High Priority:

    Yes

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

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

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

    444
    NQF:

    1799
    eMeasure ID:
    High Priority:

    Yes

    #444: Medication Management for People with Asthma

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

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

    464
    NQF:

    0657
    eMeasure ID:
    High Priority:

    Yes

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

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

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

    468
    NQF:

    3175
    eMeasure ID:
    High Priority:

    Yes

    #468: Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)

    Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment

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

    472
    NQF:
    eMeasure ID:

    CMS249v1
    High Priority:

    No

    #472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture

    Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.

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

    474
    NQF:
    eMeasure ID:
    High Priority:

    No

    #474: Zoster (Shingles) Vaccination

    The percentage of patients aged 50 years and older who have had the Shingrix zoster (shingles) vaccination

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Oncology
    • Geriatrics
    • Infectious Disease
    • Internal Medicine
    • Nephrology
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    475
    NQF:
    eMeasure ID:

    CMS349v1
    High Priority:

    No

    #475: HIV Screening

    Percentage of patients 15-65 years of age who have been tested for HIV within that age range

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Infectious Disease
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • *Family Medicine Specialty Set contains these  measures.
  2. PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 2019. There are exclusions available for most of the 11 measures that are reported. Please check your QPP Participation Status to see if you are exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category.
  3. IA: Improvement Activities - 15% of total score:  Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area,  attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days.  There are over 90 possible measures to choose from. The following are suggestions only:

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