What Are Quality Measure Benchmarks?
When clinicians or groups submit measures for the Merit-based Incentive Payment System (MIPS) quality performance category, their performance on each measure is compared against the measure's benchmark to determine how many points the measure earns. A clinician or group can receive anywhere from 1 to 10 points for each MIPS measure based on this comparison as long as the data completeness standards and case minimum requirements are met. Measures without an available historical or performance period benchmark will initially receive 0 points, even when data completeness and case minimum requirements are met (small practices will continue to receive 3 points).
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 for the 2024 performance period for eCQMs, MIPS CQMs, QCDR measures, and Medicare Part B claims measures are based on actual performance data that were submitted for the 2021 performance period. *MIPS CQMs are measures submitted using registry rules.
How Do Benchmarks Work for Multi-Performance Rate Measures?
Several MIPS quality measures require the collection and submission of data for multiple populations. This means that there can be multiple performance rates associated with a single measure. Historical benchmarks for multi-performance rate measures are created based on an "overall performance rate" (based on a weighted average, simple average, or CMS-specified performance rate):
- #9 Anti-Depressant Medication Management - Simple Average
- #52 - Simple Average
- #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention - 2nd Performance Rate
- #238 Use of High-Risk Medications in Older Adults - 1st Performance Rate
- #239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents - Simple Average
- #305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment - Simple Average
- #366 Follow-Up Care for Children Prescribed ADHD Medication (ADD) - 2nd Performance Rate
- #370 Depression Remission at Twelve Months - Weighted Average
- #392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation - 5th Performance Rate
- #394 Immunizations for Adolescents - 4th Performance Rate
- #398 Optimal Asthma Control - 1st Performance Rate
- #431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling - 2nd Performance Rate
- #493 Adult Immunization Status - Weighted Average
- #495 - Weighted Average
- #497 - Weighted Average
- #503 - 1st Performance Rate
- #504 - 2nd Performance Rate
How Are Benchmarks Displayed?
Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see table below). The table identifies the range of points generally available for each measure, based on which decile a clinician or group's performance rate falls into. Clinicians who receive a score in the first decile will receive 1 point. 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 2025 MIPS Quality Historical Benchmarks can be found here.
*Measures marked in blue (example: Measure 130) can only earn a maximum score of 7 points. Topped-out means that the national median performance rate is so high that there is no meaningful difference in performance between clinicians.
Specialty Measure Set
Show Measures with 10 Point Potential
Quality Benchmarks displayed:
| M. Name | M. ID | Coll Type | Dec 1 | Dec 2 | Dec 3 | Dec 4 | Dec 5 | Dec 6 | Dec 7 | Dec 8 | Dec 9 | Dec 10 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Diabetes: Glycemic Status Assessment Greater Than 9% | 001 | MIPS CQM | 99.00 - 90.01 | 90.00 - 80.01 | 80.00 - 70.01 | 70.00 - 60.01 | 60.00 - 50.01 | 50.00 - 40.01 | 40.00 - 30.01 | 30.00 - 20.01 | 20.00 - 10.01 | <= 10.00 |
| Diabetes: Glycemic Status Assessment Greater Than 9% | 001 | Medicare Part B Claims | 99.00 - 90.01 | 90.00 - 80.01 | 80.00 - 70.01 | 70.00 - 60.01 | 60.00 - 50.01 | 50.00 - 40.01 | 40.00 - 30.01 | 30.00 - 20.01 | 20.00 - 10.01 | <= 10.00 |
| Diabetes: Glycemic Status Assessment Greater Than 9% | 001 | eCQM | 99.49 - 93.99 | 93.98 - 71.69 | 71.68 - 49.54 | 49.53 - 36.73 | 36.72 - 29.54 | 29.53 - 24.86 | 24.85 - 20.87 | 20.86 - 17.19 | 17.18 - 12.51 | <= 12.50 |
| Diabetes: Glycemic Status Assessment Greater Than 9% | 001SSP (Only available for SSP ACOs reporting the APP Plus) | Medicare CQM | 80.94 - 49.20 | 49.19 - 38.29 | 38.28 - 29.77 | 29.76 - 25.94 | 25.93 - 22.28 | 22.27 - 18.94 | 18.93 - 14.34 | 14.33 - 10.15 | 10.14 - 7.04 | <= 7.03 |
| 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) | 005 | MIPS CQM | 73.40 - 87.68 | 87.69 - 96.61 | 96.62 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| 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) | 005 | eCQM | 50.00 - 67.34 | 67.35 - 74.18 | 74.19 - 77.33 | 77.34 - 79.76 | 79.77 - 81.73 | 81.74 - 83.81 | 83.82 - 86.18 | 86.19 - 89.53 | 89.54 - 93.32 | >= 93.33 |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | 006 | MIPS CQM | 38.16 - 70.13 | 70.14 - 80.56 | 80.57 - 92.15 | 92.16 - 99.37 | 99.38 - 99.99 | -- | -- | -- | -- | 100.00 |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) | 007 | MIPS CQM | 75.00 - 90.81 | 90.82 - 98.14 | 98.15 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) | 007 | eCQM | 55.56 - 78.45 | 78.46 - 82.69 | 82.70 - 85.47 | 85.48 - 87.49 | 87.50 - 89.24 | 89.25 - 90.48 | 90.49 - 91.90 | 91.91 - 93.54 | 93.55 - 95.96 | >= 95.97 |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 008 | MIPS CQM | 69.05 - 95.78 | 95.79 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 008 | eCQM | 57.14 - 83.32 | 83.33 - 87.92 | 87.93 - 90.31 | 90.32 - 92.18 | 92.19 - 93.64 | 93.65 - 94.73 | 94.74 - 95.64 | 95.65 - 96.66 | 96.67 - 98.14 | >= 98.15 |
| Antidepressant Medication Management | 009 | eCQM | 18.13 - 40.93 | 40.94 - 50.42 | 50.43 - 55.09 | 55.10 - 57.54 | 57.55 - 59.85 | 59.86 - 62.44 | 62.45 - 65.37 | 65.38 - 72.11 | 72.12 - 86.66 | >= 86.67 |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 012 | eCQM | 0.84 - 20.36 | 20.37 - 51.71 | 51.72 - 73.40 | 73.41 - 83.97 | 83.98 - 91.29 | 91.30 - 94.92 | 94.93 - 97.22 | 97.23 - 99.08 | 99.09 - 99.99 | 100.00 |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 019 | eCQM | 6.56 - 60.46 | 60.47 - 81.26 | 81.27 - 88.51 | 88.52 - 92.23 | 92.24 - 94.29 | 94.30 - 96.22 | 96.23 - 97.74 | 97.75 - 99.00 | 99.01 - 99.99 | 100.00 |
| Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | 024 | MIPS CQM | 0.84 - 17.81 | 17.82 - 83.77 | 83.78 - 93.48 | 93.49 - 97.72 | 97.73 - 99.99 | -- | -- | -- | -- | 100.00 |
| Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | 024 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 039 | MIPS CQM | 0.31 - 6.36 | 6.37 - 28.86 | 28.87 - 45.49 | 45.50 - 55.70 | 55.71 - 63.95 | 63.96 - 72.02 | 72.03 - 80.64 | 80.65 - 88.95 | 88.96 - 98.99 | >= 99.00 |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 039 | Medicare Part B Claims | 0.68 - 32.34 | 32.35 - 57.27 | 57.28 - 67.43 | 67.44 - 79.00 | 79.01 - 87.25 | 87.26 - 94.62 | 94.63 - 98.67 | 98.68 - 99.99 | -- | 100.00 |
| Advance Care Plan | 047 | MIPS CQM | 0.33 - 30.93 | 30.94 - 68.44 | 68.45 - 86.89 | 86.90 - 95.61 | 95.62 - 99.12 | 99.13 - 99.99 | -- | -- | -- | 100.00 |
| Advance Care Plan | 047 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 048 | MIPS CQM | 1.26 - 64.65 | 64.66 - 92.01 | 92.02 - 98.64 | 98.65 - 99.95 | 99.96 - 99.99 | -- | -- | -- | -- | 100.00 |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 050 | MIPS CQM | 1.51 - 81.96 | 81.97 - 89.57 | 89.58 - 96.56 | 96.57 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy | 052 | MIPS CQM | 0.42 - 45.04 | 45.05 - 73.63 | 73.64 - 90.37 | 90.38 - 95.73 | 95.74 - 98.75 | 98.76 - 99.99 | -- | -- | -- | 100.00 |
| Appropriate Treatment for Upper Respiratory Infection (URI) | 065 | MIPS CQM | 38.75 - 91.79 | 91.80 - 95.70 | 95.71 - 97.67 | 97.68 - 98.88 | 98.89 - 99.50 | 99.51 - 99.99 | -- | -- | -- | 100.00 |
| Appropriate Treatment for Upper Respiratory Infection (URI) | 065 | eCQM | 33.33 - 70.91 | 70.92 - 82.25 | 82.26 - 87.49 | 87.50 - 90.70 | 90.71 - 93.16 | 93.17 - 95.34 | 95.35 - 97.15 | 97.16 - 99.01 | 99.02 - 99.99 | 100.00 |
| Appropriate Testing for Pharyngitis | 066 | MIPS CQM | 27.08 - 89.12 | 89.13 - 95.44 | 95.45 - 98.86 | 98.87 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Appropriate Testing for Pharyngitis | 066 | eCQM | 2.00 - 21.03 | 21.04 - 53.24 | 53.25 - 67.41 | 67.42 - 75.62 | 75.63 - 81.02 | 81.03 - 86.03 | 86.04 - 89.41 | 89.42 - 92.08 | 92.09 - 94.94 | >= 94.95 |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Breast Cancer Screening | 112 (Not available in Traditional MIPS) | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Breast Cancer Screening | 112 (Not available in Traditional MIPS) | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Breast Cancer Screening | 112 (Not available in Traditional MIPS) | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Breast Cancer Screening | 112SSP (Only available for SSP ACOs reporting the APP Plus) | Medicare CQM | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 |
| Colorectal Cancer Screening | 113 (Not available in Traditional MIPS) | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Colorectal Cancer Screening | 113 (Not available in Traditional MIPS) | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Colorectal Cancer Screening | 113 (Not available in Traditional MIPS) | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Colorectal Cancer Screening | 113SSP (Only available for SSP ACOs reporting the APP Plus) | Medicare CQM | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 |
| Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | 116 | MIPS CQM | 21.05 - 80.72 | 80.73 - 90.76 | 90.77 - 93.82 | 93.83 - 95.69 | 95.70 - 97.39 | 97.40 - 98.26 | 98.27 - 99.52 | 99.53 - 99.99 | -- | 100.00 |
| Diabetes: Eye Exam | 117 | MIPS CQM | 1.80 - 71.06 | 71.07 - 93.19 | 93.20 - 99.37 | 99.38 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Diabetes: Eye Exam | 117 | eCQM | 0.45 - 5.87 | 5.88 - 15.37 | 15.38 - 26.77 | 26.78 - 43.00 | 43.01 - 80.36 | 80.37 - 98.92 | 98.93 - 99.62 | 99.63 - 99.99 | -- | 100.00 |
| Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%) | 118 | MIPS CQM | 47.46 - 76.48 | 76.49 - 82.64 | 82.65 - 86.62 | 86.63 - 90.77 | 90.78 - 96.60 | 96.61 - 99.99 | -- | -- | -- | 100.00 |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation | 126 | MIPS CQM | 0.32 - 21.27 | 21.28 - 57.39 | 57.40 - 79.83 | 79.84 - 94.05 | 94.06 - 99.45 | 99.46 - 99.99 | -- | -- | -- | 100.00 |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear | 127 | MIPS CQM | 0.54 - 41.99 | 42.00 - 80.82 | 80.83 - 94.61 | 94.62 - 99.27 | 99.28 - 99.99 | -- | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 (Not available in Traditional MIPS) | MIPS CQM | 0.17 - 7.37 | 7.38 - 17.23 | 17.24 - 20.55 | 20.56 - 49.55 | 49.56 - 70.53 | 70.54 - 86.20 | 86.21 - 93.47 | 93.48 - 96.68 | 96.69 - 99.99 | 100.00 |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 (Not available in Traditional MIPS) | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 (Not available in Traditional MIPS) | eCQM | 4.50 - 31.25 | 31.26 - 38.64 | 38.65 - 61.59 | 61.60 - 77.90 | 77.91 - 85.70 | 85.71 - 90.16 | 90.17 - 91.49 | 91.50 - 94.75 | 94.76 - 96.68 | >= 96.69 |
| Documentation of Current Medications in the Medical Record | 130 | MIPS CQM | 3.65 - 78.37 | 78.38 - 96.33 | 96.34 - 99.48 | 99.49 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Documentation of Current Medications in the Medical Record | 130 | eCQM | 2.94 - 60.95 | 60.96 - 80.44 | 80.45 - 88.89 | 88.90 - 93.32 | 93.33 - 95.97 | 95.98 - 97.75 | 97.76 - 98.86 | 98.87 - 99.64 | 99.65 - 99.95 | >= 99.96 |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | MIPS CQM | 0.07 - 40.33 | 40.34 - 76.29 | 76.30 - 94.00 | 94.01 - 98.96 | 98.97 - 99.81 | 99.82 - 99.99 | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | Medicare Part B Claims | 24.03 - 87.85 | 87.86 - 99.54 | 99.55 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | eCQM | 0.07 - 2.69 | 2.70 - 11.41 | 11.42 - 21.64 | 21.65 - 31.78 | 31.79 - 42.68 | 42.69 - 53.93 | 53.94 - 67.47 | 67.48 - 80.71 | 80.72 - 93.43 | >= 93.44 |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134SSP (Only available for SSP ACOs reporting the APP Plus) | Medicare CQM | 11.44 - 32.50 | 32.51 - 45.66 | 45.67 - 54.48 | 54.49 - 59.26 | 59.27 - 65.55 | 65.56 - 70.54 | 70.55 - 76.10 | 76.11 - 82.16 | 82.17 - 92.33 | >= 92.34 |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care. | 141 | MIPS CQM | 34.95 - 98.44 | 98.45 - 99.39 | 99.40 - 99.68 | 99.69 - 99.86 | 99.87 - 99.99 | -- | -- | -- | -- | 100.00 |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care. | 141 | Medicare Part B Claims | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | eCQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Oncology: Medical and Radiation - Plan of Care for Pain | 144 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy | 145 | MIPS CQM | 1.83 - 68.30 | 68.31 - 95.03 | 95.04 - 99.27 | 99.28 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy | 145 | Medicare Part B Claims | 1.44 - 34.99 | 35.00 - 80.29 | 80.30 - 95.34 | 95.35 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Falls: Plan of Care | 155 | MIPS CQM | 16.19 - 95.37 | 95.38 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy | 176 | MIPS CQM | 4.00 - 24.99 | 25.00 - 52.93 | 52.94 - 79.52 | 79.53 - 94.43 | 94.44 - 99.16 | 99.17 - 99.99 | -- | -- | -- | 100.00 |
| Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | MIPS CQM | 24.33 - 81.58 | 81.59 - 90.64 | 90.65 - 96.33 | 96.34 - 98.51 | 98.52 - 99.61 | 99.62 - 99.99 | -- | -- | -- | 100.00 |
| Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | MIPS CQM | 0.11 - 64.72 | 64.73 - 90.90 | 90.91 - 97.52 | 97.53 - 99.39 | 99.40 - 99.88 | 99.89 - 99.99 | -- | -- | -- | 100.00 |
| Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | MIPS CQM | 13.67 - 78.43 | 78.44 - 90.76 | 90.77 - 92.95 | 92.96 - 96.63 | 96.64 - 99.79 | 99.80 - 99.99 | -- | -- | -- | 100.00 |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | MIPS CQM | 0.71 - 79.39 | 79.40 - 99.29 | 99.30 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Medicare Part B Claims | 0.71 - 98.50 | 98.51 - 99.82 | 99.83 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Functional Outcome Assessment | 182 | MIPS CQM | 57.69 - 99.58 | 99.59 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | MIPS CQM | 51.72 - 95.44 | 95.45 - 98.89 | 98.90 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | MIPS CQM | 68.18 - 96.16 | 96.17 - 99.17 | 99.18 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | eCQM | 41.31 - 92.01 | 92.02 - 94.98 | 94.99 - 96.41 | 96.42 - 97.40 | 97.41 - 98.06 | 98.07 - 98.67 | 98.68 - 99.13 | 99.14 - 99.70 | 99.71 - 99.99 | 100.00 |
| Sexually Transmitted Infection (STI) Testing for People with HIV | 205 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Sexually Transmitted Infection (STI) Testing for People with HIV | 205 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Knee Impairments | 217 | MIPS CQM | 6.67 - 44.06 | 44.07 - 61.89 | 61.90 - 67.65 | 67.66 - 76.73 | 76.74 - 83.49 | 83.50 - 93.93 | 93.94 - 99.99 | -- | -- | 100.00 |
| Functional Status Change for Patients with Hip Impairments | 218 | MIPS CQM | 19.35 - 47.36 | 47.37 - 58.32 | 58.33 - 67.49 | 67.50 - 74.99 | 75.00 - 81.59 | 81.60 - 93.74 | 93.75 - 99.99 | -- | -- | 100.00 |
| Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | 219 | MIPS CQM | 11.76 - 45.36 | 45.37 - 59.17 | 59.18 - 68.63 | 68.64 - 78.25 | 78.26 - 83.32 | 83.33 - 92.30 | 92.31 - 99.99 | -- | -- | 100.00 |
| Functional Status Change for Patients with Low Back Impairments | 220 | MIPS CQM | 15.79 - 41.17 | 41.18 - 59.99 | 60.00 - 69.56 | 69.57 - 78.37 | 78.38 - 85.10 | 85.11 - 93.74 | 93.75 - 97.89 | 97.90 - 99.99 | -- | 100.00 |
| Functional Status Change for Patients with Shoulder Impairments | 221 | MIPS CQM | 18.18 - 42.69 | 42.70 - 59.83 | 59.84 - 70.82 | 70.83 - 77.16 | 77.17 - 84.52 | 84.53 - 91.29 | 91.30 - 96.71 | 96.72 - 99.99 | -- | 100.00 |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | MIPS CQM | 30.00 - 52.26 | 52.27 - 63.63 | 63.64 - 66.66 | 66.67 - 73.41 | 73.42 - 86.12 | 86.13 - 98.38 | 98.39 - 99.99 | -- | -- | 100.00 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | MIPS CQM | 4.17 - 41.66 | 41.67 - 74.99 | 75.00 - 90.76 | 90.77 - 98.64 | 98.65 - 99.99 | -- | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Medicare Part B Claims | 8.51 - 79.99 | 80.00 - 95.64 | 95.65 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | eCQM | 4.17 - 19.22 | 19.23 - 33.32 | 33.33 - 46.57 | 46.58 - 61.56 | 61.57 - 75.96 | 75.97 - 87.40 | 87.41 - 94.73 | 94.74 - 98.81 | 98.82 - 99.99 | 100.00 |
| Controlling High Blood Pressure | 236 | MIPS CQM | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 |
| Controlling High Blood Pressure | 236 | Medicare Part B Claims | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 |
| Controlling High Blood Pressure | 236 | eCQM | 4.76 - 45.27 | 45.28 - 55.55 | 55.56 - 61.53 | 61.54 - 65.60 | 65.61 - 68.97 | 68.98 - 71.99 | 72.00 - 74.99 | 75.00 - 78.69 | 78.70 - 84.03 | >= 84.04 |
| Controlling High Blood Pressure | 236SSP (Only available for SSP ACOs reporting the APP Plus) | Medicare CQM | 13.68 - 44.86 | 44.87 - 62.32 | 62.33 - 68.16 | 68.17 - 70.14 | 70.15 - 72.53 | 72.54 - 74.08 | 74.09 - 74.69 | 74.70 - 76.41 | 76.42 - 82.80 | >= 82.81 |
| Use of High-Risk Medications in Older Adults | 238 | MIPS CQM | 9.62 - 0.03 | 0.02 - 0.01 | -- | -- | -- | -- | -- | -- | -- | 0.00 |
| Use of High-Risk Medications in Older Adults | 238 | eCQM | 30.71 - 15.86 | 15.85 - 10.17 | 10.16 - 5.24 | 5.23 - 2.03 | 2.02 - 0.67 | 0.66 - 0.15 | 0.14 - 0.01 | -- | -- | 0.00 |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | 239 | eCQM | 2.94 - 22.68 | 22.69 - 26.90 | 26.91 - 29.52 | 29.53 - 31.78 | 31.79 - 33.32 | 33.33 - 36.50 | 36.51 - 42.29 | 42.30 - 53.54 | 53.55 - 68.39 | >= 68.40 |
| Childhood Immunization Status | 240 | eCQM | 1.23 - 7.99 | 8.00 - 12.92 | 12.93 - 16.38 | 16.39 - 19.50 | 19.51 - 23.06 | 23.07 - 27.01 | 27.02 - 30.66 | 30.67 - 35.13 | 35.14 - 43.47 | >= 43.48 |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | MIPS CQM | 2.86 - 34.77 | 34.78 - 38.27 | 38.28 - 40.90 | 40.91 - 69.67 | 69.68 - 89.14 | 89.15 - 97.08 | 97.09 - 99.99 | -- | -- | 100.00 |
| Barrett's Esophagus | 249 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Barrett's Esophagus | 249 | Medicare Part B Claims | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Radical Prostatectomy Pathology Reporting | 250 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Radical Prostatectomy Pathology Reporting | 250 | Medicare Part B Claims | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| 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 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | MIPS CQM | 4.35 - 27.73 | 27.74 - 72.66 | 72.67 - 97.72 | 97.73 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| 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 | 0.44 - 6.81 | 6.82 - 27.67 | 27.68 - 55.68 | 55.69 - 77.37 | 77.38 - 95.59 | 95.60 - 99.99 | -- | -- | -- | 100.00 |
| Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy. | 279 | MIPS CQM | 45.97 - 99.62 | 99.63 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Dementia: Cognitive Assessment | 281 | eCQM | 0.38 - 3.22 | 3.23 - 8.03 | 8.04 - 15.37 | 15.38 - 25.60 | 25.61 - 38.94 | 38.95 - 49.99 | 50.00 - 58.36 | 58.37 - 71.34 | 71.35 - 86.88 | >= 86.89 |
| Dementia: Functional Status Assessment | 282 | MIPS CQM | 4.09 - 98.58 | 98.59 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia | 286 | MIPS CQM | 3.70 - 97.20 | 97.21 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Dementia: Education and Support of Caregivers for Patients with Dementia | 288 | MIPS CQM | 12.86 - 99.06 | 99.07 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease | 291 | MIPS CQM | 23.06 - 78.67 | 78.68 - 92.30 | 92.31 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Rehabilitative Therapy Referral for Patients with Parkinson's Disease | 293 | MIPS CQM | 9.09 - 91.29 | 91.30 - 99.99 | -- | -- | -- | -- | -- | -- | -- | 100.00 |
| Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | 303 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Initiation and Engagement of Substance Use Disorder Treatment | 305 | eCQM | 0.40 - 1.78 | 1.79 - 2.84 | 2.85 - 3.81 | 3.82 - 4.63 | 4.64 - 5.55 | 5.56 - 6.62 | 6.63 - 7.99 | 8.00 - 10.49 | 10.50 - 16.19 | >= 16.20 |
| Cervical Cancer Screening | 309 | eCQM | 0.27 - 5.55 | 5.56 - 19.04 | 19.05 - 29.40 | 29.41 - 36.69 | 36.70 - 43.29 | 43.30 - 49.52 | 49.53 - 55.84 | 55.85 - 63.63 | 63.64 - 73.54 | >= 73.55 |
| Chlamydia Screening in Women | 310 | eCQM | 0.27 - 1.54 | 1.55 - 2.78 | 2.79 - 4.34 | 4.35 - 7.46 | 7.47 - 13.08 | 13.09 - 19.99 | 20.00 - 28.65 | 28.66 - 35.53 | 35.54 - 47.80 | >= 47.81 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | MIPS CQM | 0.13 - 18.85 | 18.86 - 32.48 | 32.49 - 54.27 | 54.28 - 82.64 | 82.65 - 97.65 | 97.66 - 99.99 | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Medicare Part B Claims | 0.27 - 34.75 | 34.76 - 89.98 | 89.99 - 98.32 | 98.33 - 99.67 | 99.68 - 99.99 | -- | -- | -- | -- | 100.00 |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | eCQM | 0.05 - 5.04 | 5.05 - 15.10 | 15.11 - 19.84 | 19.85 - 23.19 | 23.20 - 26.23 | 26.24 - 29.11 | 29.12 - 32.25 | 32.26 - 36.55 | 36.56 - 45.83 | >= 45.84 |
| Falls: Screening for Future Fall Risk | 318 | eCQM | 0.15 - 7.92 | 7.93 - 29.03 | 29.04 - 50.46 | 50.47 - 67.96 | 67.97 - 81.56 | 81.57 - 90.85 | 90.86 - 96.66 | 96.67 - 99.04 | 99.05 - 99.85 | >= 99.86 |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | MIPS CQM | 5.73 - 88.73 | 88.74 - 95.29 | 95.30 - 97.72 | 97.73 - 99.14 | 99.15 - 99.99 | -- | -- | -- | -- | 100.00 |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Medicare Part B Claims | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information | 321 | CAHPS Survey Vendor | 64.39 - 77.91 | 77.92 - 80.14 | 80.15 - 81.67 | 81.68 - 82.80 | 82.81 - 83.98 | 83.99 - 84.97 | 84.98 - 86.04 | 86.05 - 87.17 | 87.18 - 88.41 | >= 88.42 |
| CAHPS for MIPS SSM: How Well Providers Communicate | 321 | CAHPS Survey Vendor | 82.65 - 91.91 | 91.92 - 92.96 | 92.97 - 93.41 | 93.42 - 93.88 | 93.89 - 94.26 | 94.27 - 94.56 | 94.57 - 94.93 | 94.94 - 95.33 | 95.34 - 95.83 | >= 95.84 |
| CAHPS for MIPS SSM: Patient’s Rating of Provider | 321 | CAHPS Survey Vendor | 83.71 - 90.20 | 90.21 - 91.23 | 91.24 - 91.81 | 91.82 - 92.40 | 92.41 - 92.71 | 92.72 - 93.03 | 93.04 - 93.47 | 93.48 - 93.87 | 93.88 - 94.49 | >= 94.50 |
| CAHPS for MIPS SSM: Access to Specialists | 321 | CAHPS Survey Vendor | 61.83 - 70.18 | 70.19 - 72.24 | 72.25 - 73.73 | 73.74 - 74.95 | 74.96 - 75.95 | 75.96 - 77.14 | 77.15 - 78.05 | 78.06 - 79.53 | 79.54 - 80.99 | >= 81.00 |
| CAHPS for MIPS SSM: Health Promotion and Education | 321 | CAHPS Survey Vendor | 45.72 - 59.55 | 59.56 - 61.75 | 61.76 - 63.11 | 63.12 - 64.44 | 64.45 - 65.57 | 65.58 - 66.64 | 66.65 - 67.71 | 67.72 - 69.22 | 69.23 - 70.91 | >= 70.92 |
| CAHPS for MIPS SSM: Shared Decision Making | 321 | CAHPS Survey Vendor | 47.91 - 56.85 | 56.86 - 58.91 | 58.92 - 60.25 | 60.26 - 61.53 | 61.54 - 62.57 | 62.58 - 63.49 | 63.50 - 64.40 | 64.41 - 65.72 | 65.73 - 67.53 | >= 67.54 |
| CAHPS for MIPS SSM: Care Coordination | 321 | CAHPS Survey Vendor | 72.95 - 83.29 | 83.30 - 84.36 | 84.37 - 85.05 | 85.06 - 85.63 | 85.64 - 86.21 | 86.22 - 86.66 | 86.67 - 87.25 | 87.26 - 87.80 | 87.81 - 88.50 | >= 88.51 |
| CAHPS for MIPS SSM: Courteous and Helpful Office Staff | 321 | CAHPS Survey Vendor | 75.70 - 90.78 | 90.79 - 91.71 | 91.72 - 92.36 | 92.37 - 92.88 | 92.89 - 93.32 | 93.33 - 93.61 | 93.62 - 94.03 | 94.04 - 94.44 | 94.45 - 94.94 | >= 94.95 |
| CAHPS for MIPS SSM: Stewardship of Patient Resources | 321 | CAHPS Survey Vendor | 12.25 - 20.67 | 20.68 - 22.74 | 22.75 - 24.45 | 24.46 - 25.67 | 25.68 - 27.05 | 27.06 - 28.14 | 28.15 - 29.50 | 29.51 - 30.76 | 30.77 - 32.73 | >= 32.74 |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | MIPS CQM | 30.00 - 71.42 | 71.43 - 86.43 | 86.44 - 95.76 | 95.77 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | MIPS CQM | 91.67 - 74.36 | 74.35 - 59.18 | 59.17 - 38.61 | 38.60 - 18.76 | 18.75 - 8.34 | 8.33 - 3.46 | 3.45 - 0.01 | -- | -- | 0.00 |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | MIPS CQM | 31.69 - 75.72 | 75.73 - 88.88 | 88.89 - 92.97 | 92.98 - 96.28 | 96.29 - 99.99 | -- | -- | -- | -- | 100.00 |
| Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse) | 335 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Maternity Care: Postpartum Follow-up and Care Coordination | 336 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Viral Suppression | 338 | MIPS CQM | 76.60 - 89.18 | 89.19 - 90.92 | 90.93 - 93.15 | 93.16 - 95.11 | 95.12 - 98.71 | 98.72 - 99.47 | 99.48 - 99.99 | -- | -- | 100.00 |
| HIV Viral Suppression | 338 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Annual Retention in Care | 340 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Annual Retention in Care | 340 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | 344 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | 350 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | 351 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Anastomotic Leak Intervention | 354 | MIPS CQM | 8.33 - 4.64 | 4.63 - 0.63 | 0.62 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 |
| Unplanned Reoperation within the 30-Day Postoperative Period | 355 | MIPS CQM | 5.00 - 0.41 | 0.40 - 0.01 | -- | -- | -- | -- | -- | -- | -- | 0.00 |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | 356 | MIPS CQM | 6.73 - 3.04 | 3.03 - 1.46 | 1.45 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 |
| Surgical Site Infection (SSI) | 357 | MIPS CQM | 4.55 - 0.52 | 0.51 - 0.01 | -- | -- | -- | -- | -- | -- | -- | 0.00 |
| Patient-Centered Surgical Risk Assessment and Communication | 358 | MIPS CQM | 0.85 - 45.70 | 45.71 - 95.03 | 95.04 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| 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 | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines | 364 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Follow-Up Care for Children Prescribed ADHD Medication | 366 | eCQM | 11.89 - 23.90 | 23.91 - 29.73 | 29.74 - 33.32 | 33.33 - 37.19 | 37.20 - 40.67 | 40.68 - 46.60 | 46.61 - 51.34 | 51.35 - 56.64 | 56.65 - 65.61 | >= 65.62 |
| Depression Remission at Twelve Months | 370 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Depression Remission at Twelve Months | 370 | eCQM | 0.83 - 2.35 | 2.36 - 4.45 | 4.46 - 6.05 | 6.06 - 7.85 | 7.86 - 9.99 | 10.00 - 12.49 | 12.50 - 15.69 | 15.70 - 19.99 | 20.00 - 28.68 | >= 28.69 |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | MIPS CQM | 1.54 - 56.71 | 56.72 - 89.99 | 90.00 - 97.36 | 97.37 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | eCQM | 0.57 - 5.76 | 5.77 - 15.68 | 15.69 - 24.95 | 24.96 - 33.78 | 33.79 - 42.85 | 42.86 - 52.17 | 52.18 - 62.49 | 62.50 - 79.53 | 79.54 - 95.75 | >= 95.76 |
| Functional Status Assessment for Total Hip Replacement | 376 | eCQM | 0.73 - 3.88 | 3.89 - 6.26 | 6.27 - 9.37 | 9.38 - 15.99 | 16.00 - 27.42 | 27.43 - 31.81 | 31.82 - 38.09 | 38.10 - 46.71 | 46.72 - 55.80 | >= 55.81 |
| Functional Status Assessments for Heart Failure | 377 | eCQM | 0.04 - 0.16 | 0.17 - 0.28 | 0.29 - 0.69 | 0.70 - 0.82 | 0.83 - 1.08 | 1.09 - 2.70 | 2.71 - 4.46 | 4.47 - 6.65 | 6.66 - 12.30 | >= 12.31 |
| Children Who Have Dental Decay or Cavities | 378 | eCQM | 97.92 - 59.87 | 59.86 - 47.95 | 47.94 - 43.49 | 43.48 - 25.94 | 25.93 - 16.31 | 16.30 - 12.33 | 12.32 - 8.48 | 8.47 - 7.46 | 7.45 - 3.35 | <= 3.34 |
| Primary Caries Prevention Intervention as Offered by Dentists | 379 | eCQM | 3.17 - 5.04 | 5.05 - 11.10 | 11.11 - 13.90 | 13.91 - 16.04 | 16.05 - 19.16 | 19.17 - 23.38 | 23.39 - 25.52 | 25.53 - 32.84 | 32.85 - 36.39 | >= 36.40 |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | eCQM | 0.40 - 1.98 | 1.99 - 5.04 | 5.05 - 17.77 | 17.78 - 26.96 | 26.97 - 37.96 | 37.97 - 45.32 | 45.33 - 58.17 | 58.18 - 72.19 | 72.20 - 92.64 | >= 92.65 |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | MIPS CQM | 1.15 - 3.65 | 3.66 - 75.78 | 75.79 - 97.65 | 97.66 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | MIPS CQM | 71.43 - 87.09 | 87.10 - 91.94 | 91.95 - 93.32 | 93.33 - 94.66 | 94.67 - 96.66 | 96.67 - 97.13 | 97.14 - 99.99 | -- | -- | 100.00 |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | MIPS CQM | 59.09 - 68.17 | 68.18 - 71.87 | 71.88 - 74.99 | 75.00 - 77.38 | 77.39 - 79.99 | 80.00 - 81.81 | 81.82 - 83.66 | 83.67 - 85.75 | 85.76 - 89.79 | >= 89.80 |
| 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 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| 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 | 1.75 - 18.41 | 18.42 - 24.31 | 24.32 - 30.62 | 30.63 - 36.64 | 36.65 - 43.32 | 43.33 - 51.71 | 51.72 - 59.99 | 60.00 - 71.42 | 71.43 - 85.18 | >= 85.19 |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Medicare Part B Claims | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Lung Cancer Reporting (Resection Specimens) | 396 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Lung Cancer Reporting (Resection Specimens) | 396 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Melanoma Reporting | 397 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Melanoma Reporting | 397 | Medicare Part B Claims | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Optimal Asthma Control | 398 | MIPS CQM | 14.81 - 33.32 | 33.33 - 59.41 | 59.42 - 73.41 | 73.42 - 82.95 | 82.96 - 95.37 | 95.38 - 98.53 | 98.54 - 99.99 | -- | -- | 100.00 |
| One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation | 400 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Anesthesiology Smoking Abstinence | 404 | MIPS CQM | 12.60 - 52.93 | 52.94 - 65.83 | 65.84 - 75.44 | 75.45 - 80.36 | 80.37 - 84.29 | 84.30 - 87.92 | 87.93 - 93.12 | 93.13 - 98.34 | 98.35 - 99.99 | 100.00 |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Medicare Part B Claims | 0.60 - 10.55 | 10.56 - 21.69 | 21.70 - 36.66 | 36.67 - 59.21 | 59.22 - 72.61 | 72.62 - 81.25 | 81.26 - 87.13 | 87.14 - 92.49 | 92.50 - 99.99 | 100.00 |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | MIPS CQM | 16.00 - 14.01 | 14.00 - 12.01 | 12.00 - 10.01 | 10.00 - 8.01 | 8.00 - 6.01 | 6.00 - 4.01 | 4.00 - 2.01 | 2.00 - 1.01 | 1.00 - 0.01 | 0.00 |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Medicare Part B Claims | 16.00 - 14.01 | 14.00 - 12.01 | 12.00 - 10.01 | 10.00 - 8.01 | 8.00 - 6.01 | 6.00 - 4.01 | 4.00 - 2.01 | 2.00 - 1.01 | 1.00 - 0.01 | 0.00 |
| Psoriasis: Clinical Response to Systemic Medications | 410 | MIPS CQM | 6.67 - 59.25 | 59.26 - 80.24 | 80.25 - 90.90 | 90.91 - 97.36 | 97.37 - 99.99 | -- | -- | -- | -- | 100.00 |
| Door to Puncture Time for Endovascular Stroke Treatment | 413 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | MIPS CQM | 63.39 - 93.89 | 93.90 - 96.68 | 96.69 - 97.75 | 97.76 - 98.49 | 98.50 - 99.43 | 99.44 - 99.99 | -- | -- | -- | 100.00 |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | MIPS CQM | 61.90 - 14.05 | 14.04 - 4.36 | 4.35 - 3.46 | 3.45 - 2.01 | 2.00 - 0.01 | -- | -- | -- | -- | 0.00 |
| Osteoporosis Management in Women Who Had a Fracture | 418 | MIPS CQM | 1.56 - 6.22 | 6.23 - 9.22 | 9.23 - 11.88 | 11.89 - 14.00 | 14.01 - 16.35 | 16.36 - 19.27 | 19.28 - 23.07 | 23.08 - 30.33 | 30.34 - 47.72 | >= 47.73 |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Medicare Part B Claims | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| 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 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy | 430 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | MIPS CQM | 1.06 - 8.32 | 8.33 - 22.85 | 22.86 - 49.99 | 50.00 - 71.42 | 71.43 - 88.88 | 88.89 - 99.29 | 99.30 - 99.99 | -- | -- | 100.00 |
| Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 432 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | MIPS CQM | 15.88 - 42.84 | 42.85 - 58.73 | 58.74 - 68.80 | 68.81 - 73.65 | 73.66 - 78.02 | 78.03 - 83.52 | 83.53 - 89.26 | 89.27 - 99.77 | 99.78 - 99.99 | 100.00 |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | eCQM | 24.47 - 67.85 | 67.86 - 73.09 | 73.10 - 76.00 | 76.01 - 78.19 | 78.20 - 80.04 | 80.05 - 81.97 | 81.98 - 83.94 | 83.95 - 86.12 | 86.13 - 89.00 | >= 89.01 |
| Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician | 440 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | 441 | MIPS CQM | 1.72 - 28.40 | 28.41 - 34.99 | 35.00 - 43.91 | 43.92 - 49.22 | 49.23 - 51.81 | 51.82 - 56.01 | 56.02 - 61.10 | 61.11 - 68.16 | 68.17 - 79.20 | >= 79.21 |
| Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | 445 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Workup Prior to Endometrial Ablation | 448 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer | 450 | MIPS CQM | 42.86 - 80.42 | 80.43 - 85.15 | 85.16 - 89.99 | 90.00 - 95.44 | 95.45 - 98.79 | 98.80 - 99.99 | -- | -- | -- | 100.00 |
| 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 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better) | 453 | MIPS CQM | 27.78 - 17.96 | 17.95 - 14.12 | 14.11 - 10.88 | 10.87 - 9.53 | 9.52 - 7.67 | 7.66 - 6.26 | 6.25 - 3.62 | 3.61 - 0.25 | 0.24 - 0.01 | 0.00 |
| Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better) | 457 | MIPS CQM | 60.00 - 24.33 | 24.32 - 15.01 | 15.00 - 10.27 | 10.26 - 6.26 | 6.25 - 4.89 | 4.88 - 3.46 | 3.45 - 0.01 | -- | -- | 0.00 |
| Back Pain After Lumbar Surgery | 459 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Leg Pain After Lumbar Surgery | 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 | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | 464 | MIPS CQM | 82.19 - 91.60 | 91.61 - 94.01 | 94.02 - 97.65 | 97.66 - 98.24 | 98.25 - 98.88 | 98.89 - 99.49 | 99.50 - 99.99 | -- | -- | 100.00 |
| 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 Primary Total Knee Replacement | 470 | MIPS CQM | 0.15 - 3.56 | 3.57 - 6.74 | 6.75 - 11.53 | 11.54 - 15.42 | 15.43 - 19.56 | 19.57 - 28.77 | 28.78 - 34.80 | 34.81 - 44.91 | 44.92 - 60.65 | >= 60.66 |
| Functional Status After Lumbar Surgery | 471 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| HIV Screening | 475 | eCQM | 0.10 - 0.87 | 0.88 - 2.59 | 2.60 - 4.79 | 4.80 - 9.08 | 9.09 - 16.96 | 16.97 - 23.68 | 23.69 - 30.35 | 30.36 - 37.59 | 37.60 - 47.71 | >= 47.72 |
| Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia | 476 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Multimodal Pain Management | 477 | MIPS CQM | 84.00 - 85.99 | 86.00 - 87.99 | 88.00 - 89.99 | 90.00 - 91.99 | 92.00 - 93.99 | 94.00 - 95.99 | 96.00 - 97.99 | 98.00 - 98.99 | 99.00 - 99.99 | 100.00 |
| Functional Status Change for Patients with Neck Impairments | 478 | MIPS CQM | 23.81 - 47.05 | 47.06 - 57.13 | 57.14 - 68.17 | 68.18 - 77.77 | 77.78 - 87.23 | 87.24 - 94.99 | 95.00 - 99.99 | -- | -- | 100.00 |
| Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer | 481 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate | 482 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) | 483 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Psoriasis - Improvement in Patient-Reported Itch Severity | 485 | MIPS CQM | 4.44 - 22.57 | 22.58 - 32.08 | 32.09 - 38.21 | 38.22 - 43.09 | 43.10 - 47.99 | 48.00 - 53.84 | 53.85 - 61.66 | 61.67 - 71.63 | 71.64 - 96.96 | >= 96.97 |
| Dermatitis – Improvement in Patient-Reported Itch Severity | 486 | MIPS CQM | 6.45 - 19.22 | 19.23 - 26.41 | 26.42 - 32.25 | 32.26 - 37.82 | 37.83 - 42.59 | 42.60 - 49.46 | 49.47 - 56.31 | 56.32 - 69.99 | 70.00 - 95.11 | >= 95.12 |
| Kidney Health Evaluation | 488 | MIPS CQM | 1.91 - 15.86 | 15.87 - 24.80 | 24.81 - 33.50 | 33.51 - 43.35 | 43.36 - 47.18 | 47.19 - 51.04 | 51.05 - 54.64 | 54.65 - 66.98 | 66.99 - 96.24 | >= 96.25 |
| Kidney Health Evaluation | 488 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy | 489 | MIPS CQM | 25.00 - 60.92 | 60.93 - 70.40 | 70.41 - 77.80 | 77.81 - 95.08 | 95.09 - 99.99 | -- | -- | -- | -- | 100.00 |
| Appropriate Intervention of Immune-related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors | 490 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status | 491 | MIPS CQM | 20.29 - 75.75 | 75.76 - 88.74 | 88.75 - 95.30 | 95.31 - 97.86 | 97.87 - 99.67 | 99.68 - 99.99 | -- | -- | -- | 100.00 |
| Adult Immunization Status | 493 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level) | 494 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood | 495 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument | 496 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Preventive Care and Wellness (composite) | 497 | MIPS CQM | 0.09 - 5.01 | 5.02 - 10.62 | 10.63 - 15.55 | 15.56 - 19.94 | 19.95 - 24.06 | 24.07 - 28.25 | 28.26 - 32.85 | 32.86 - 38.85 | 38.86 - 47.45 | >= 47.46 |
| Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy | 499 | MIPS CQM | 4.39 - 42.85 | 42.86 - 53.15 | 53.16 - 63.88 | 63.89 - 70.44 | 70.45 - 76.26 | 76.27 - 80.64 | 80.65 - 84.84 | 84.85 - 89.65 | 89.66 - 94.93 | >= 94.94 |
| Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up | 500 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up | 501 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder | 502 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Gains in Patient Activation Measure (PAM®) Scores at 12 Months | 503 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk | 504 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Reduction in Suicidal Ideation or Behavior Symptoms | 505 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy | 506 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Germline Testing for Ovarian Cancer Patients | 507 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Melanoma: Tracking and Evaluation of Recurrence | 509 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| First Year Standardized Kidney Transplant Waitlist Ratio (FYSWR) | 510 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Percentage of Prevalent Patients Waitlisted for Kidney Transplant (PPPW) and Percentage of Prevalent Patients Waitlisted for Kidney Transplant in Active Status (aPPPW) | 511 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR) | 512 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Patient Reported Falls and Plan of Care | 513 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Diagnostic Delay of Venous Thromboembolism in Primary Care | 514 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes | 515 | eCQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hepatitis C Virus (HCV): Sustained Virological Response (SVR) | 516 | MIPS CQM | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Melanoma: – Appropriate Surgical Margins | AAD12 | QCDR Measure | 38.38 - 75.26 | 75.27 - 84.47 | 84.48 - 93.74 | 93.75 - 96.69 | 96.70 - 99.99 | -- | -- | -- | -- | 100.00 |
| Psoriasis – Appropriate Assessment & Treatment of Severe Psoriasis | AAD15 | QCDR Measure | 6.45 - 34.31 | 34.32 - 54.03 | 54.04 - 69.56 | 69.57 - 76.24 | 76.25 - 86.41 | 86.42 - 91.66 | 91.67 - 94.99 | 95.00 - 97.85 | 97.86 - 99.99 | 100.00 |
| Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures | AAD16 | QCDR Measure | 83.33 - 11.77 | 11.76 - 5.03 | 5.02 - 3.07 | 3.06 - 1.70 | 1.69 - 0.32 | 0.31 - 0.01 | -- | -- | -- | 0.00 |
| Actinic Keratosis: Patient-Reported Treatment Effectiveness and Care Satisfaction | AAD20 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Actinic Keratosis: Appropriate Documentation and Shared Decision Making of AK | AAD21 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Skin Cancer: Biopsy Reporting Time - Clinician to Patient | AAD6 | QCDR Measure | 29.12 - 90.55 | 90.56 - 96.81 | 96.82 - 98.90 | 98.91 - 99.47 | 99.48 - 99.79 | 99.80 - 99.99 | -- | -- | -- | 100.00 |
| Chronic Skin Conditions: Patient Reported Quality-of-Life | AAD8 | QCDR Measure | 0.76 - 3.77 | 3.78 - 5.42 | 5.43 - 11.47 | 11.48 - 15.85 | 15.86 - 21.39 | 21.40 - 28.16 | 28.17 - 58.96 | 58.97 - 74.93 | 74.94 - 83.45 | >= 83.46 |
| Tympanostomy Tubes: Topical Ear Drop Monotherapy for Acute Otorrhea | AAO12 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan | AAO13 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Age-Related Hearing Loss: Comprehensive Audiometric Evaluation | AAO16 | QCDR Measure | 6.25 - 51.91 | 51.92 - 66.07 | 66.08 - 71.30 | 71.31 - 80.69 | 80.70 - 85.18 | 85.19 - 91.19 | 91.20 - 94.46 | 94.47 - 96.32 | 96.33 - 98.81 | >= 98.82 |
| Tympanostomy Tubes: Comprehensive Audiometric Evaluation | AAO20 | QCDR Measure | 3.65 - 19.32 | 19.33 - 25.63 | 25.64 - 41.95 | 41.96 - 68.88 | 68.89 - 81.56 | 81.57 - 93.06 | 93.07 - 95.04 | 95.05 - 95.57 | 95.58 - 97.06 | >= 97.07 |
| Otitis Media with Effusion (OME): Comprehensive Audiometric Evaluation for Chronic OME > or = 3 months | AAO21 | QCDR Measure | 3.16 - 28.56 | 28.57 - 44.43 | 44.44 - 56.77 | 56.78 - 63.32 | 63.33 - 79.30 | 79.31 - 87.21 | 87.22 - 93.17 | 93.18 - 97.36 | 97.37 - 99.99 | 100.00 |
| Standard Benign Positional Paroxysmal Vertigo (BPPV) Management | AAO32 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | 0.00 |
| Tympanostomy Tubes: Resolution of Otitis Media with Effusion (OME) in Adults and Children | AAO36 | QCDR Measure | 0.56 - 1.07 | 1.08 - 2.32 | 2.33 - 3.22 | 3.23 - 3.63 | 3.64 - 8.61 | 8.62 - 15.30 | 15.31 - 19.61 | 19.62 - 52.70 | 52.71 - 82.85 | >= 82.86 |
| Dysphonia: Laryngeal Examination | AAO37 | QCDR Measure | 3.67 - 42.30 | 42.31 - 58.89 | 58.90 - 66.93 | 66.94 - 72.07 | 72.08 - 80.76 | 80.77 - 88.55 | 88.56 - 89.99 | 90.00 - 92.58 | 92.59 - 95.41 | >= 95.42 |
| Neck Mass Evaluation | AAO39 | QCDR Measure | 1.37 - 1.59 | 1.60 - 2.26 | 2.27 - 3.76 | 3.77 - 9.08 | 9.09 - 10.63 | 10.64 - 11.60 | 11.61 - 14.74 | 14.75 - 16.89 | 16.90 - 21.42 | >= 21.43 |
| Tonsillectomy: Post-Tonsillectomy Pain Management in Pediatric Patients | AAO40 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Tonsillectomy: Post-Tonsillectomy Hemorrhage | AAO41 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Obstructive Sleep Apnea: Improvement of Obstructive Sleep Apnea after a Corrective Surgical Procedure | AAO42 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Otolaryngologic Surgical Procedures: Avoidance of Unnecessary Antibiotic Use | AAO43 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Measuring the Value-Functions of Primary Care: Comprehensiveness of Care | ABFM13 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Measuring the Value-Functions of Primary Care: Physician Level Continuity of Care Measure | ABFM14 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Low Flow Inhalational General Anesthesia | ABG44 | QCDR Measure | 32.19 - 86.86 | 86.87 - 95.99 | 96.00 - 98.57 | 98.58 - 99.23 | 99.24 - 99.33 | 99.34 - 99.59 | 99.60 - 99.81 | 99.82 - 99.99 | -- | 100.00 |
| Aspiration prevention in patients with gastric distension | ABG45 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | ACEP22 | QCDR Measure | 27.91 - 48.86 | 48.87 - 55.26 | 55.27 - 60.07 | 60.08 - 63.53 | 63.54 - 66.44 | 66.45 - 74.40 | 74.41 - 79.89 | 79.90 - 82.70 | 82.71 - 97.89 | >= 97.90 |
| Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD | ACEP25 | QCDR Measure | 21.62 - 76.63 | 76.64 - 80.94 | 80.95 - 86.74 | 86.75 - 89.57 | 89.58 - 92.52 | 92.53 - 94.49 | 94.50 - 96.80 | 96.81 - 97.97 | 97.98 - 98.87 | >= 98.88 |
| Foley Catheter: Appropriate Foley catheter use in the emergency department | ACEP31 | QCDR Measure | 20.42 - 42.75 | 42.76 - 59.21 | 59.22 - 91.17 | 91.18 - 95.88 | 95.89 - 98.26 | 98.27 - 99.99 | -- | -- | -- | 100.00 |
| ED Median Time from ED arrival to ED departure for all Adult Patients | ACEP50 | QCDR Measure | 301.00 - 226.01 | 226.00 - 208.01 | 208.00 - 193.01 | 193.00 - 180.01 | 180.00 - 171.01 | 171.00 - 161.01 | 161.00 - 155.01 | 155.00 - 147.01 | 147.00 - 132.01 | <= 132.00 |
| ED Median Time from ED arrival to ED departure for all Pediatric ED Patients | ACEP51 | QCDR Measure | 184.00 - 164.01 | 164.00 - 140.01 | 140.00 - 133.01 | 133.00 - 125.01 | 125.00 - 119.01 | 119.00 - 113.01 | 113.00 - 105.01 | 105.00 - 99.01 | 99.00 - 90.01 | <= 90.00 |
| Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Acute Atraumatic Low Back Pain | ACEP52 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Use of Imaging for Recurrent Renal Colic | ACEP53 | QCDR Measure | 27.96 - 32.27 | 32.28 - 36.23 | 36.24 - 42.15 | 42.16 - 45.34 | 45.35 - 46.51 | 46.52 - 55.60 | 55.61 - 65.72 | 65.73 - 75.25 | 75.26 - 86.82 | >= 86.83 |
| Chest Pain – Avoidance of admission for adult patients with low-risk chest pain. | ACEP59 | QCDR Measure | 64.15 - 85.23 | 85.24 - 88.18 | 88.19 - 90.78 | 90.79 - 93.06 | 93.07 - 95.61 | 95.62 - 97.22 | 97.23 - 98.04 | 98.05 - 98.78 | 98.79 - 99.81 | >= 99.82 |
| Syncope – Avoidance of admission for adult patients with low-risk syncope | ACEP60 | QCDR Measure | 71.89 - 83.66 | 83.67 - 86.29 | 86.30 - 88.34 | 88.35 - 90.35 | 90.36 - 91.56 | 91.57 - 92.83 | 92.84 - 93.93 | 93.94 - 95.77 | 95.78 - 97.98 | >= 97.99 |
| Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup | ACEP61 | QCDR Measure | 63.16 - 51.51 | 51.50 - 43.36 | 43.35 - 40.31 | 40.30 - 37.79 | 37.78 - 33.89 | 33.88 - 30.78 | 30.77 - 27.73 | 27.72 - 24.76 | 24.75 - 19.88 | <= 19.87 |
| Avoidance of Opioid therapy for dental pain. | ACEP62 | QCDR Measure | 65.79 - 75.92 | 75.93 - 80.28 | 80.29 - 81.71 | 81.72 - 83.16 | 83.17 - 85.04 | 85.05 - 87.49 | 87.50 - 88.88 | 88.89 - 92.01 | 92.02 - 96.08 | >= 96.09 |
| Avoidance of Acute High-Risk Prescriptions in geriatric patients at discharge | ACEP63 | QCDR Measure | 11.59 - 6.69 | 6.68 - 6.23 | 6.22 - 5.53 | 5.52 - 5.21 | 5.20 - 4.69 | 4.68 - 4.25 | 4.24 - 3.76 | 3.75 - 3.26 | 3.25 - 1.90 | <= 1.89 |
| Avoidance of admission for adult patients in Emergency Department with low-risk Deep Vein Thrombosis (DVT). | ACEP64 | QCDR Measure | 27.11 - 44.43 | 44.44 - 52.02 | 52.03 - 57.55 | 57.56 - 63.71 | 63.72 - 69.73 | 69.74 - 79.71 | 79.72 - 91.88 | 91.89 - 97.36 | 97.37 - 99.99 | 100.00 |
| Appropriate Utilization of Imaging in rAAA (ruptured Abdominal Aortic Aneurysm) patients in Emergency Department | ACEP65 | QCDR Measure | 1.68 - 13.39 | 13.40 - 33.06 | 33.07 - 48.85 | 48.86 - 60.59 | 60.60 - 62.49 | 62.50 - 69.80 | 69.81 - 78.97 | 78.98 - 82.37 | 82.38 - 84.30 | >= 84.31 |
| Avoidance of Admission for Atrial Fibrillation | ACEP67 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Point-of-care ultrasound (POCUS) in Cardiac Arrest | ACEP68 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Blood Pressure Control Among Adult ED Patients with Nontraumatic Intracranial Hemorrhage | ACEP69 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Syphilis testing among ED patients with a positive pregnancy test | ACEP70 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Emergency Medicine: Coagulation Studies in Patients Presenting to the Emergency Department with No Coagulopathy or Bleeding | ACEP71 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Sepsis diagnosis and management: Lactate Level Measurement, Antibiotics Ordered, and Fluid Septic shock outcomes: Lactate clearance rate of greater than equal to 10% | ACEP72 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hepatitis B Safety Screening | ACR10 | QCDR Measure | 9.74 - 33.81 | 33.82 - 43.87 | 43.88 - 52.61 | 52.62 - 58.40 | 58.41 - 65.63 | 65.64 - 68.84 | 68.85 - 71.90 | 71.91 - 83.07 | 83.08 - 86.83 | >= 86.84 |
| Disease Activity Measurement for Patients with PsA | ACR12 | QCDR Measure | 11.79 - 67.26 | 67.27 - 83.01 | 83.02 - 86.51 | 86.52 - 90.90 | 90.91 - 93.80 | 93.81 - 96.14 | 96.15 - 97.47 | 97.48 - 99.17 | 99.18 - 99.99 | 100.00 |
| Gout: Serum Urate Target | ACR14 | QCDR Measure | 10.59 - 41.17 | 41.18 - 49.99 | 50.00 - 54.99 | 55.00 - 59.76 | 59.77 - 62.64 | 62.65 - 65.89 | 65.90 - 69.92 | 69.93 - 75.50 | 75.51 - 81.15 | >= 81.16 |
| Safe Hydroxychloroquine Dosing | ACR15 | QCDR Measure | 31.57 - 56.51 | 56.52 - 62.94 | 62.95 - 69.54 | 69.55 - 71.98 | 71.99 - 76.35 | 76.36 - 80.06 | 80.07 - 84.99 | 85.00 - 88.67 | 88.68 - 91.97 | >= 91.98 |
| Methotrexate to Biologic Adherence to Treatment Pathway for Patients with Rheumatoid Arthritis | ACR17 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Patient Reported Outcome Physical Function Survey for Patients with Rheumatology Conditions | ACR18 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoiding the Prolonged Use of Moderate/High Dose Glucocorticoids for Patients with Systemic Lupus Erythematosus | ACR19 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hydroxychloroquine Use in Patients with Systemic Lupus Erythematosus | ACR20 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan) | ACRAD34 | QCDR Measure | 37.32 - 70.37 | 70.38 - 81.69 | 81.70 - 82.06 | 82.07 - 86.89 | 86.90 - 89.70 | 89.71 - 91.22 | 91.23 - 94.31 | 94.32 - 95.99 | 96.00 - 96.60 | >= 96.61 |
| Comprehensive Reporting of Coronary Artery Calcification (CAC) on Chest CT | ACRAD44 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism | ACRAD45 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Standardized Spine Fracture Classification Using Validated Systems | ACRAD46 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cement Use for Displaced Femoral Neck Fracture in Older Adults | AJRR10 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| 90-Day Composite Complication Rate for Degenerative Spine Procedures | AJRR15 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Physical Health Outcomes in Total Hip and Knee Arthroplasty | AJRR16 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Improvement in Pain Assessment Following Spine Fusion Procedures | AJRR17 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Postoperative Ambulation | AJRR7 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Risk-Standardized Routine Discharge Rate Following Elective Primary Hip and Knee Arthroplasty | AJRR9 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure | AQI18 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Patient-Reported Experience with Anesthesia | AQI48 | QCDR Measure | 83.33 - 89.71 | 89.72 - 92.83 | 92.84 - 94.19 | 94.20 - 94.74 | 94.75 - 95.67 | 95.68 - 95.96 | 95.97 - 96.46 | 96.47 - 97.13 | 97.14 - 97.77 | >= 97.78 |
| Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass | AQI65 | QCDR Measure | 48.08 - 75.87 | 75.88 - 88.35 | 88.36 - 96.90 | 96.91 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Ambulatory Glucose Management | AQI71 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Neuromuscular Blockade and Quantitative Train-of-Four | AQI79 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Continuation of Buprenorphine for Inpatient Surgical Patients or Methadone Therapy during the Perioperative Period for Inpatient and Ambulatory Surgical Patients | AQI80 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Use of Peripheral Nerve Blocks for Pain Management in Hip Fracture Patients | AQI81 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Intraoperative Antibiotic Redosing in Open Cardiac Surgeries | AQI82 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment | AQUA14 | QCDR Measure | 21.54 - 10.29 | 10.28 - 8.28 | 8.27 - 4.51 | 4.50 - 3.46 | 3.45 - 2.70 | 2.69 - 2.34 | 2.33 - 1.53 | 1.52 - 0.63 | 0.62 - 0.01 | 0.00 |
| Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures | AQUA15 | QCDR Measure | 31.71 - 53.72 | 53.73 - 80.18 | 80.19 - 87.26 | 87.27 - 90.90 | 90.91 - 94.73 | 94.74 - 96.29 | 96.30 - 97.19 | 97.20 - 98.13 | 98.14 - 99.99 | 100.00 |
| Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease | AQUA16 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Non-Muscle Invasive Bladder Cancer: Initial Management/Surveillance for Non-Muscle Invasive Bladder Cancer | AQUA35 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Prostate Cancer: Confirmation Biopsy in Newly Diagnosed Patients on Active Surveillance | AQUA36 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy | AQUA8 | QCDR Measure | 14.52 - 6.24 | 6.23 - 3.42 | 3.41 - 2.21 | 2.20 - 1.33 | 1.32 - 0.99 | 0.98 - 0.64 | 0.63 - 0.01 | -- | -- | 0.00 |
| Echocardiogram Stewardship in Congestive Heart Failure (CHF): Avoiding Repeat Tests without Clinical Indication | AVBC2 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| SGLT2 Inhibitors for Patients with Chronic Kidney Disease (CKD) with or without type 2 diabetes mellitus | AVBC3 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Noninvasive Ischemic Imaging Stewardship in Chronic Coronary Disease: Avoiding Testing without Clinical Indication | AVBC4 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Urinary Bladder Cancer: Complete Analysis and Timely Reporting | CAP30 | QCDR Measure | 32.56 - 72.31 | 72.32 - 80.08 | 80.09 - 92.10 | 92.11 - 95.11 | 95.12 - 95.80 | 95.81 - 98.30 | 98.31 - 99.99 | -- | -- | 100.00 |
| Molecular Assessment: Biomarkers in Non-Small Cell Lung Cancer | CAP34 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Squamous Cell Skin Cancer: Complete Reporting | CAP40 | QCDR Measure | 0.10 - 35.70 | 35.71 - 70.90 | 70.91 - 94.51 | 94.52 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Barrett’s Esophagus: Complete Analysis with Appropriate Consultation | CAP42 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Complete Reporting of Gastrointestinal Metaplasia | CAP43 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Molecular Assessment for Endometrial Carcinoma | CAP44 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoidance of Opiates for Low Back Pain or Migraines | ECPR46 | QCDR Measure | 86.70 - 91.30 | 91.31 - 94.07 | 94.08 - 95.77 | 95.78 - 97.31 | 97.32 - 98.09 | 98.10 - 98.65 | 98.66 - 99.99 | -- | -- | 100.00 |
| Discharge Prescription of Naloxone after Opioid Poisoning or Overdose | ECPR51 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Treatment of Psychosis and Agitation in the Emergency Department | ECPR52 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain | ECPR55 | QCDR Measure | 77.06 - 80.49 | 80.50 - 83.02 | 83.03 - 85.25 | 85.26 - 88.58 | 88.59 - 91.82 | 91.83 - 93.93 | 93.94 - 97.15 | 97.16 - 99.99 | -- | 100.00 |
| Opioid Withdrawal: Initiation of Medication for Opioid Use Disorder (MOUD) and Referral to Outpatient Opioid Treatment | ECPR56 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Patient-Reported Understanding of Discharge Diagnosis and Plan of Care | ECPR58 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Patient Reported Trust in Provider | ECPR59 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoidance of Advanced Imaging for Pediatric Patients with Unprovoked, Generalized Seizure | ECPR60 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Inhaled Corticosteroid for Patients with Acute Asthma Exacerbation | ECPR61 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases | EPREOP31 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Upper or Lower Quadrant Edema | FOTO4 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change in Balance Confidence | FOTO5 | QCDR Measure | 6.25 - 33.81 | 33.82 - 42.85 | 42.86 - 45.44 | 45.45 - 52.37 | 52.38 - 61.10 | 61.11 - 76.31 | 76.32 - 79.99 | 80.00 - 81.47 | 81.48 - 93.32 | >= 93.33 |
| Functional Status Change for Patients Post Stroke | FOTO7 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Jaw Functional Status Scale (JFSS) Change | FOTO8 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate follow-up interval based on pathology findings in screening colonoscopy | GIQIC23 | QCDR Measure | 8.00 - 43.93 | 43.94 - 83.39 | 83.40 - 91.83 | 91.84 - 93.38 | 93.39 - 95.51 | 95.52 - 98.09 | 98.10 - 99.15 | 99.16 - 99.99 | -- | 100.00 |
| Screening Colonoscopy Adenoma Detection Rate | GIQIC26 | QCDR Measure | 19.91 - 27.42 | 27.43 - 31.75 | 31.76 - 36.10 | 36.11 - 38.08 | 38.09 - 39.60 | 39.61 - 42.65 | 42.66 - 45.10 | 45.11 - 47.53 | 47.54 - 52.04 | >= 52.05 |
| Appropriate Utilization of Vancomycin for Cellulitis | HCPR24 | QCDR Measure | 47.79 - 73.71 | 73.72 - 76.23 | 76.24 - 82.12 | 82.13 - 86.79 | 86.80 - 94.92 | 94.93 - 98.69 | 98.70 - 99.99 | -- | -- | 100.00 |
| Physician’s Orders for Life-Sustaining Treatment (POLST) Form | HCPR25 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) Placement | HCPR27 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD) | HCPR28 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoidance of DVT Ultrasound for Patients Diagnosed with Cellulitis | HCPR29 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoidance of Sliding-Scale Insulin Monotherapy for Admitted Diabetic Patients | HCPR30 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Point-of-Care Ultrasound for Evaluation and Management of Shock | HCPR31 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Medication for Alcohol Use Disorder (MAUD) for Patients with Alcohol Use Disorder | HCPR32 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Functional Status Change for Patients with Vestibular Dysfunction | HM7 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better | IRIS1 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Diabetic Macular Edema - Loss of Visual Acuity | IRIS13 | QCDR Measure | 96.97 - 99.03 | 99.04 - 99.42 | 99.43 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 |
| Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells | IRIS17 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Glaucoma – Intraocular Pressure Reduction | IRIS2 | QCDR Measure | 77.78 - 87.00 | 87.01 - 89.49 | 89.50 - 90.82 | 90.83 - 91.92 | 91.93 - 92.97 | 92.98 - 93.97 | 93.98 - 94.90 | 94.91 - 96.03 | 96.04 - 97.46 | >= 97.47 |
| Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days | IRIS23 | QCDR Measure | 14.81 - 75.85 | 75.86 - 81.47 | 81.48 - 84.60 | 84.61 - 88.70 | 88.71 - 90.57 | 90.58 - 93.32 | 93.33 - 94.63 | 94.64 - 96.66 | 96.67 - 98.29 | >= 98.30 |
| Endothelial Keratoplasty – Dislocation Requiring Surgical Intervention | IRIS38 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure | IRIS39 | QCDR Measure | 17.78 - 26.10 | 26.11 - 31.81 | 31.82 - 34.91 | 34.92 - 39.99 | 40.00 - 44.32 | 44.33 - 54.89 | 54.90 - 59.36 | 59.37 - 60.45 | 60.46 - 85.28 | >= 85.29 |
| Amblyopia: Interocular visual acuity | IRIS50 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Complications After Cataract Surgery | IRIS54 | QCDR Measure | 3.32 - 1.14 | 1.13 - 0.72 | 0.71 - 0.50 | 0.49 - 0.34 | 0.33 - 0.20 | 0.19 - 0.01 | -- | -- | -- | 0.00 |
| Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days | IRIS58 | QCDR Measure | 70.00 - 80.76 | 80.77 - 81.81 | 81.82 - 83.77 | 83.78 - 84.60 | 84.61 - 85.70 | 85.71 - 87.03 | 87.04 - 89.64 | 89.65 - 91.03 | 91.04 - 94.53 | >= 94.54 |
| Regaining Vision After Cataract Surgery | IRIS59 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery | IRIS61 | QCDR Measure | 26.32 - 61.21 | 61.22 - 70.72 | 70.73 - 80.63 | 80.64 - 84.99 | 85.00 - 88.27 | 88.28 - 90.90 | 90.91 - 93.09 | 93.10 - 95.76 | 95.77 - 97.66 | >= 97.67 |
| Exudative Age-Related Macular Degeneration: Gain of Visual Acuity | IRIS63 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Use of Anxiety Severity Measure | MBHR1 | QCDR Measure | 25.20 - 86.10 | 86.11 - 89.18 | 89.19 - 93.23 | 93.24 - 95.86 | 95.87 - 98.27 | 98.28 - 99.22 | 99.23 - 99.99 | -- | -- | 100.00 |
| Trauma Screening and Re-Traumatization Prevention | MBHR19 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Anxiety Response at 6-months | MBHR2 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Differential Cognitive Assessment with Safety and Risk Counseling | MBHR20 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children | MBHR7 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke. | MEDNAX55 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hammer Toe Outcome | MEX5 | QCDR Measure | 0.89 - 2.12 | 2.13 - 4.71 | 4.72 - 6.29 | 6.30 - 12.42 | 12.43 - 15.58 | 15.59 - 20.74 | 20.75 - 31.99 | 32.00 - 49.99 | 50.00 - 74.00 | >= 74.01 |
| Patients Suffering From a Neck Injury who Improve Physical Function | MSK1 | QCDR Measure | 33.33 - 41.66 | 41.67 - 45.82 | 45.83 - 49.99 | 50.00 - 53.05 | 53.06 - 55.16 | 55.17 - 58.05 | 58.06 - 60.70 | 60.71 - 63.15 | 63.16 - 69.22 | >= 69.23 |
| Patients Suffering From a Knee Injury who Improve Pain | MSK10 | QCDR Measure | 40.00 - 46.66 | 46.67 - 48.56 | 48.57 - 49.99 | 50.00 - 52.16 | 52.17 - 53.84 | 53.85 - 55.55 | 55.56 - 57.13 | 57.14 - 59.08 | 59.09 - 61.28 | >= 61.29 |
| Patients Suffering From an Upper Extremity Injury who Improve Physical Function | MSK2 | QCDR Measure | 38.71 - 45.36 | 45.37 - 48.36 | 48.37 - 49.99 | 50.00 - 52.04 | 52.05 - 53.36 | 53.37 - 54.71 | 54.72 - 56.24 | 56.25 - 58.11 | 58.12 - 60.70 | >= 60.71 |
| Patients Suffering From a Back Injury who Improve Physical Function | MSK3 | QCDR Measure | 33.33 - 41.66 | 41.67 - 45.15 | 45.16 - 48.14 | 48.15 - 49.99 | 50.00 - 53.28 | 53.29 - 55.21 | 55.22 - 56.85 | 56.86 - 58.81 | 58.82 - 61.89 | >= 61.90 |
| Patients Suffering From a Lower Extremity Injury who Improve Physical Function | MSK4 | QCDR Measure | 36.67 - 45.70 | 45.71 - 49.88 | 49.89 - 51.78 | 51.79 - 53.84 | 53.85 - 55.55 | 55.56 - 57.13 | 57.14 - 59.62 | 59.63 - 62.08 | 62.09 - 64.99 | >= 65.00 |
| Patients Suffering From a Knee Injury who Improve Physical Function | MSK5 | QCDR Measure | 36.00 - 46.42 | 46.43 - 49.27 | 49.28 - 50.93 | 50.94 - 52.16 | 52.17 - 53.46 | 53.47 - 54.80 | 54.81 - 55.99 | 56.00 - 57.13 | 57.14 - 58.96 | >= 58.97 |
| Patients Suffering From a Neck Injury who Improve Pain | MSK6 | QCDR Measure | 33.33 - 42.85 | 42.86 - 46.66 | 46.67 - 49.99 | 50.00 - 52.25 | 52.26 - 54.16 | 54.17 - 56.24 | 56.25 - 59.08 | 59.09 - 60.86 | 60.87 - 63.63 | >= 63.64 |
| Patients Suffering From an Upper Extremity Injury who Improve Pain | MSK7 | QCDR Measure | 37.50 - 44.99 | 45.00 - 48.27 | 48.28 - 49.99 | 50.00 - 52.10 | 52.11 - 53.56 | 53.57 - 55.31 | 55.32 - 57.17 | 57.18 - 59.25 | 59.26 - 61.89 | >= 61.90 |
| Patients Suffering From a Back Injury who Improve Pain | MSK8 | QCDR Measure | 37.14 - 43.99 | 44.00 - 47.61 | 47.62 - 49.99 | 50.00 - 52.73 | 52.74 - 54.99 | 55.00 - 57.13 | 57.14 - 59.08 | 59.09 - 61.21 | 61.22 - 64.28 | >= 64.29 |
| Patients Suffering From a Lower Extremity Injury who Improve Pain | MSK9 | QCDR Measure | 40.00 - 46.66 | 46.67 - 49.99 | 50.00 - 51.31 | 51.32 - 53.32 | 53.33 - 54.88 | 54.89 - 56.60 | 56.61 - 58.84 | 58.85 - 61.53 | 61.54 - 64.28 | >= 64.29 |
| Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients | MUSIC4 | QCDR Measure | 55.00 - 61.53 | 61.54 - 64.70 | 64.71 - 69.15 | 69.16 - 76.35 | 76.36 - 79.27 | 79.28 - 80.94 | 80.95 - 81.07 | 81.08 - 85.70 | 85.71 - 91.66 | >= 91.67 |
| Repeat screening or surveillance colonoscopy recommended within one year due to inadequate bowel preparation | NHCR4 | QCDR Measure | 29.79 - 61.89 | 61.90 - 84.37 | 84.38 - 92.48 | 92.49 - 94.99 | 95.00 - 96.26 | 96.27 - 97.72 | 97.73 - 99.27 | 99.28 - 99.99 | -- | 100.00 |
| Dihydropyrimidine Dehydrogenase (DPD) Deficiency Testing Prior to Fluoropyrimidine Treatment | OQH1 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Oncology: Advance Care Planning in Metastatic Cancer Patients | PIMSH1 | QCDR Measure | 0.90 - 9.19 | 9.20 - 33.29 | 33.30 - 44.59 | 44.60 - 48.99 | 49.00 - 55.49 | 55.50 - 60.29 | 60.30 - 67.79 | 67.80 - 77.29 | 77.30 - 87.69 | >= 87.70 |
| Oncology: Hepatitis B Serology Testing and Prophylactic Treatment Prior to Receiving Anti-CD20 Targeting Drugs | PIMSH10 | QCDR Measure | 1.90 - 15.99 | 16.00 - 43.09 | 43.10 - 54.79 | 54.80 - 61.49 | 61.50 - 68.29 | 68.30 - 71.69 | 71.70 - 74.59 | 74.60 - 86.39 | 86.40 - 93.49 | >= 93.50 |
| Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy | PIMSH13 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Oncology: Utilization of Prophylactic GCSF for Cancer Patients Receiving Low-Risk Chemotherapy (inverse measure) | PIMSH17 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Antiemetic Therapy for Low- and Minimal-Emetic-Risk Antineoplastic Agents - Avoidance of Overuse (Lower Score - Better) | PIMSH19 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Antiemetic Therapy for High- and Moderate-Emetic-Risk Antineoplastic Agents | PIMSH20 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Oncology: Screening and Achieving Resolution or Improvement of Distress for Cancer Care | PIMSH21 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Oncology: Patient-Reported Pain Improvement | PIMSH4 | QCDR Measure | 27.40 - 36.59 | 36.60 - 44.49 | 44.50 - 50.79 | 50.80 - 54.29 | 54.30 - 56.79 | 56.80 - 61.29 | 61.30 - 64.09 | 64.10 - 69.44 | 69.45 - 73.69 | >= 73.70 |
| Oncology: Supportive Care Drug Utilization in Last 14 Days of Life | PIMSH9 | QCDR Measure | 18.50 - 12.71 | 12.70 - 8.31 | 8.30 - 6.01 | 6.00 - 5.01 | 5.00 - 4.71 | 4.70 - 3.71 | 3.70 - 3.61 | 3.60 - 1.41 | 1.40 - 0.01 | 0.00 |
| Use of Peripheral Nerve Block within the Emergency Department in Patients Admitted with Low Energy Hip Fracture | PQRANES1 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS) | QMM17 | QCDR Measure | 0.06 - 0.60 | 0.61 - 1.98 | 1.99 - 5.55 | 5.56 - 17.77 | 17.78 - 76.21 | 76.22 - 93.18 | 93.19 - 99.99 | -- | -- | 100.00 |
| Use of Breast Cancer Risk Score on Mammography | QMM18 | QCDR Measure | 0.03 - 36.67 | 36.68 - 86.29 | 86.30 - 97.70 | 97.71 - 99.89 | 99.90 - 99.99 | -- | -- | -- | -- | 100.00 |
| Incorporating results of concurrent studies into Final Reports for Bone Marrow Aspirate of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia | QMM21 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Low dose cancer screening recommendation for computed tomography (CT) and computed tomography angiography (CTA) of chest with diagnosis of Emphysema. | QMM23 | QCDR Measure | 0.65 - 5.93 | 5.94 - 40.43 | 40.44 - 83.77 | 83.78 - 97.77 | 97.78 - 99.99 | -- | -- | -- | -- | 100.00 |
| Use of Structured Reporting for Urine Cytology Specimens | QMM25 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Screening Abdominal Aortic Aneurysm Reporting with Recommendations | QMM26 | QCDR Measure | 1.11 - 6.24 | 6.25 - 21.26 | 21.27 - 49.00 | 49.01 - 90.32 | 90.33 - 99.99 | -- | -- | -- | -- | 100.00 |
| Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts | QMM27 | QCDR Measure | 8.70 - 13.78 | 13.79 - 28.23 | 28.24 - 69.28 | 69.29 - 99.99 | -- | -- | -- | -- | -- | 100.00 |
| Reporting Breast Arterial Calcification (BAC) on Screening Mammography | QMM28 | QCDR Measure | 0.01 - 0.06 | 0.07 - 0.30 | 0.31 - 0.66 | 0.67 - 2.80 | 2.81 - 7.88 | 7.89 - 84.40 | 84.41 - 93.60 | 93.61 - 99.97 | 99.98 - 99.99 | 100.00 |
| Use of Appropriate Classification System for Lymphoma Specimen | QMM29 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Use of Bethesda System for Reporting Thyroid Cytopathology on Fine Needle Aspirations (FNA) of Thyroid Nodule(s) | QMM30 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Intracerebral Hemorrhage (ICH) on Non-Contrast CT Head | QMM32 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Immunohistochemistry (IHC) and/or Molecular BRAF Testing Status in Metastatic Melanoma | QMM33 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Use of Appropriate Scoring System for Immunohistochemistry (IHC) for HER2/neu Testing for Invasive Breast Cancer | QMM34 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| P16 Immunohistochemistry (IHC) Staining Status in Oropharyngeal Squamous Cell Carcinoma (OPSCC) | QMM35 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| P53 Immunohistochemistry (IHC) Staining Status in Endometrial Carcinoma | QMM36 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Hepatocellular Carcinoma (HCC) Screening Recommendation for Patients with Cirrhosis of the Liver | QMM37 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Tunneled Hemodialysis Catheter Clinical Success Rate | RCOIR12 | QCDR Measure | 69.14 - 73.47 | 73.48 - 82.77 | 82.78 - 85.98 | 85.99 - 88.26 | 88.27 - 89.84 | 89.85 - 90.03 | 90.04 - 91.74 | 91.75 - 93.18 | 93.19 - 93.72 | >= 93.73 |
| Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate | RCOIR13 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Heel Pain Treatment Outcomes for Adults | REGCLR1 | QCDR Measure | 1.09 - 13.38 | 13.39 - 21.02 | 21.03 - 28.80 | 28.81 - 34.04 | 34.05 - 41.81 | 41.82 - 51.71 | 51.72 - 57.13 | 57.14 - 67.62 | 67.63 - 82.80 | >= 82.81 |
| Bunion Outcome - Adult and Adolescent | REGCLR3 | QCDR Measure | 1.71 - 2.64 | 2.65 - 4.11 | 4.12 - 6.81 | 6.82 - 9.08 | 9.09 - 11.68 | 11.69 - 24.99 | 25.00 - 31.47 | 31.48 - 39.57 | 39.58 - 72.77 | >= 72.78 |
| Offloading with Remote Monitoring | REGCLR5 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Monitor and Improve Treatment Outcomes in Chronic Wound Healing | REGCLR8 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Arteriovenous Graft Thrombectomy Clinical Success Rate | RPAQIR14 | QCDR Measure | 75.41 - 82.85 | 82.86 - 87.07 | 87.08 - 87.49 | 87.50 - 88.88 | 88.89 - 90.09 | 90.10 - 90.96 | 90.97 - 92.53 | 92.54 - 94.31 | 94.32 - 95.23 | >= 95.24 |
| Arteriovenous Fistulae Thrombectomy Clinical Success Rate | RPAQIR15 | QCDR Measure | 72.73 - 77.13 | 77.14 - 81.24 | 81.25 - 86.48 | 86.49 - 89.16 | 89.17 - 90.19 | 90.20 - 91.99 | 92.00 - 93.74 | 93.75 - 96.42 | 96.43 - 96.54 | >= 96.55 |
| High Intensity Statin Prescribed for Acute and Subacute Ischemic Stroke and Transient Ischemic Attack (TIA) | THEPQR1 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Discontinuation of Proton Pump Inhibitors for patients who do not meet criteria for long-term utilization. | THEPQR2 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Consultation to Palliative Care for Patients with End Stage Conditions | THEPQR4 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Avoidance of Head CT Scans in Recurrent Seizure Episodes Without New Head Injury. | THEPQR5 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Timely and Effective Management of Pediatric Asthma Exacerbations in the Emergency Department | THEPQR6 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Optimization of Short-term Dual Antiplatelet Therapy for High-risk Cerebrovascular Events | THEPQR7 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Ankylosing Spondylitis: Controlled Disease Or Improved Disease Function | UREQA10 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved | UREQA8 | QCDR Measure | 7.12 - 18.22 | 18.23 - 44.14 | 44.15 - 54.58 | 54.59 - 62.27 | 62.28 - 65.52 | 65.53 - 71.20 | 71.21 - 80.06 | 80.07 - 86.90 | 86.91 - 89.05 | >= 89.06 |
| Screening for Osteoporosis for Men Aged 70 Years and Older | UREQA9 | QCDR Measure | 9.64 - 13.83 | 13.84 - 18.98 | 18.99 - 22.46 | 22.47 - 32.18 | 32.19 - 35.43 | 35.44 - 37.30 | 37.31 - 42.96 | 42.97 - 46.95 | 46.96 - 52.33 | >= 52.34 |
| Nutritional Assessment and Intervention Plan in patients with Wounds and Ulcers | USWR22 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Non-Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential | USWR30 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Adequate Compression at each visit for Patients with Venous Leg Ulcers (VLUs) appropriate to arterial supply | USWR32 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Diabetic Foot Ulcer (DFU) Healing or Closure | USWR33 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Venous Leg Ulcer (VLU) Healing or Closure | USWR34 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Adequate Off-loading of Diabetic Foot Ulcers performed at each visit, appropriate to location of ulcer | USWR35 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Pressure Ulcer* (PU) Healing or Closure (ulcerations not on the lower extremity) | USWR36 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Objective Measurement of Wound Surface Area With AI-Based Imaging | USWR37 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Treatment of Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease | VHE1 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cluster Headache: Preventive Treatment Prescribed | VHE2 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Appropriate Physical Activity Counseling for patients with Neurological Conditions | VHE3 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Acute Migraine Attacks: Recommended Treatment | VHE4 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Reduction of Polyneuropathy-Related Pain | VHE5 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Documentation of Seizure Frequency | VHE6 | QCDR Measure | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |