2017 Proposed MIPS Specialty Measure Sets

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MIPS ID Number NQF/PQRS CMS E-Measure ID Data Submission Method Measure Type National Quality Strategy Domain Measure Title and Description Measure Steward
1. Allergy/Immunology/Rheumatology
0041/110 147v5 Claims, Web Interface, Registry, EHR Process Community/ Population Health Preventive Care and Screening: Influenza Immunization
  • Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
American Medical Association-Physician Consortium for Performance Improvement
0043/111 127v4 Claims, Web Interface, Registry, EHR Process Community/ Population Health Pneumonia Vaccination Status for Older Adults
  • Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
National Committee for Quality Assurance
* § 0405/160 52v4 EHR Process Effective Clinical Care HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
  • Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis
National Committee for Quality Assurance
* N/A/176 N/A Registry Process Effective Clinical Care Rheumatoid Arthritis (RA): Tuberculosis Screening
  • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
American College of Rheumatology
* N/A/177 N/A Registry Process Effective Clinical Care Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
  • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months
American College of Rheumatology
N/A/178 N/A Registry, Measures Group Process Effective Clinical Care Rheumatoid Arthritis (RA): Functional Status Assessment
  • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months
American College of Rheumatology
* N/A/179 N/A Registry Process Effective Clinical Care Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
  • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months
American College of Rheumatology
* N/A/180 N/A Registry Process Effective Clinical Care Rheumatoid Arthritis (RA): Glucocorticoid Management
  • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months
American College of Rheumatology
!! N/A/331 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
  • Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/332 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
  • Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/333 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
  • Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/334 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
  • Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
N/A/337 N/A Registry Process Effective Clinical Care Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
  • Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test
American Academy of Dermatology
! N/A/398 N/A Registry Process Efficiency and Cost Reduction Optimal Asthma Control
  • Patients ages 5-50 (pediatrics ages 5-17) whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools
Minnesota Community Measurement
+ § ! 1799/N/A N/A Registry Process Efficiency and Cost Reduction Medication Management for People with Asthma (MMA):
  • The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported.
    1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period.
    2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period.
National Committee for Quality Assurance
2. Anesthesiology
! N/A/076 N/A Claims, Registry Process Patient Safety Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections
  • Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
American Society of Anesthesiologists
! N/A/404 N/A Registry Intermediate Outcome Effective Clinical Care Anesthesiology Smoking Abstinence
  • The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.
American Society of Anesthesiologists
! 2681/424 N/A Registry Process Patient Safety Perioperative Temperature Management
  • Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
American Society of Anesthesiologists
! N/A/426 N/A Registry Process Communication and Care Coordination Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)
  • Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized
American Society of Anesthesiologists
! N/A/427 N/A Registry Process Communication and Care Coordination Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
  • Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member
American Society of Anesthesiologists
! N/A/430 N/A Registry Process Patient Safety Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
  • Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively
American Society of Anesthesiologists
0236/044 N/A Registry Process Effective Clinical Care Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
  • Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision
Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
3. Cardiology
§ 0081/005 135v4 Registry, EHR Process Effective Clinical Care Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
American Medical Association- Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* § 0083/008 144v4 Registry, EHR Process Effective Clinical Care Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
American Medical Association- Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* § 0066/118 N/A Registry Process Effective Clinical Care Chronic Stable Coronary Artery Disease: ACE Inhibitor or ARB Therapy--Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
  • Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
* § 0067/006 N/A Registry Process Effective Clinical Care Chronic Stable Coronary Artery Disease: Antiplatelet Therapy
  • Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
§ 0070/007 145v4 Registry, EHR Process Effective Clinical Care Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
  • Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker therapy
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
§ 1525/326 N/A Claims, Registry Process Effective Clinical Care Chronic Anticoagulation Therapy
  • Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
N/A/438 N/A Web Interface, Registry Process Effective Clinical Care Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period:
    • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
    • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR
    • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
§ 0070/007 145v4 Registry, EHR Process Effective Clinical Care Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
  • Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker therapy
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
* § 0068/204 164v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
  • Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.
National Committee for Quality Assurance
!! N/A/322 N/A Registry Efficiency Efficiency and Cost Reduction Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
  • Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period
American College of Cardiology
!! N/A/323 N/A Registry Efficiency Efficiency and Cost Reduction Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
  • Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA),and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status
American College of Cardiology
!! N/A/324 N/A Registry Efficiency Efficiency and Cost Reduction Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
  • Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment
American College of Cardiology
! N/A/348 N/A Registry Outcome Patient Safety HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate
  • Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD
The Heart Rhythm Society
! 2474/392 N/A Registry Outcome Patient Safety HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
  • Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is reported as four rates stratified by age and gender:
    • Reporting Age Criteria 1: Females less than 65 years of age
    • Reporting Age Criteria 2: Males less than 65 years of age
    • Reporting Age Criteria 3: Females 65 years of age and older
    • Reporting Age Criteria 4: Males 65 years of age and older
The Heart Rhythm Society
! N/A/393 N/A Registry Outcome Patient Safety HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
  • Infection rate following CIED device implantation, replacement, or revision
The Heart Rhythm Society
4. Gastroenterology
§ 0034/113 130v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Colorectal Cancer Screening
  • Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer
National Committee for Quality Assurance
§ !! 0659/185 N/A Claims, Registry Process Communication and Care Coordination Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
  • Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy
American Medical Association- Physician Consortium for Performance Improvement/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
§ !! 0658/320 N/A Claims, Registry Process Communication and Care Coordination Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
  • Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report
American Medical Association- Physician Consortium for Performance Improvement/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
§ ! N/A/343 N/A Registry Outcome Effective Clinical Care Screening Colonoscopy Adenoma Detection Rate Measure
  • The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
! N/A/390 N/A Registry Process Person and Caregiver- Centered Experience and Outcomes Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
  • Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient
  • To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment
American Medical Association- Physician Consortium for Performance Improvement/ American Gastroenterological Association
§ N/A/401 N/A Registry Process Effective Clinical Care Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
  • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period
American Medical Association- Physician Consortium for Performance Improvement/ American Gastroenterological Association
§ !! N/A/439 N/A Registry Efficiency Efficiency and Cost Reduction Age Appropriate Screening Colonoscopy
  • The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
5. Dermatology
! 0650/137 N/A Registry Structure Communication and Care Coordination Melanoma: Continuity of Care – Recall System
  • Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:
    • A target date for the next complete physical skin exam, AND
    • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment
American Academy of Dermatology/ American Medical Association- Physician Consortium for Performance Improvement
! N/A/138 N/A Registry Process Communication and Care Coordination Melanoma: Coordination of Care
  • Percentage of patients visits, regardless of age, with a new occurrence of melanoma, who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis
American Academy of Dermatology/ American Medical Association- Physician Consortium for Performance Improvement
!! 0562/224 N/A Registry Process Efficiency and Cost Reduction Melanoma: Overutilization of Imaging Studies in Melanoma
  • Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.
American Academy of Dermatology/ American Medical Association- Physician Consortium for Performance Improvement
! N/A/265 N/A Registry Process Communication and Care Coordination Biopsy Follow-Up
  • Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
American Academy of Dermatology
N/A/337 N/A Registry Process Effective Clinical Care Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
  • Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test
American Academy of Dermatology
! N/A/410 Claims, Registry Outcome Person and Caregiver Centered Experience and Outcomes Psoriasis: Clinical Response to Oral Systemic or Biologic Medications
  • Percentage of psoriasis patients receiving oral systemic or biologic therapy who meet minimal physician- or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.
American Academy of Dermatology
6. Emergency Medicine
* !! N/A/066 146v4 Registry, EHR Process Efficiency and Cost Reduction Appropriate Testing for Children with Pharyngitis
  • Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode
National Committee for Quality Assurance
!! 0653/091 N/A Claims, Registry Process Effective Clinical Care Acute Otitis Externa (AOE): Topical Therapy
  • Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations
American Academy of Otolaryngology-Head and Neck Surgery
!! 0654/093 N/A Claims, Registry Process Efficiency and Cost Reduction Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
  • Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
American Academy of Otolaryngology-Head and Neck Surgery
§ !! 0058/116 N/A Registry Process Efficiency and Cost Reduction Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use
  • Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode
National Committee for Quality Assurance
0651/254 N/A Claims, Registry Process Effective Clinical Care Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
  • Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans- vaginal ultrasound to determine pregnancy location
American College of Emergency Physicians
N/A/255 N/A Claims, Registry Process Effective Clinical Care Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
  • Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED)
American College of Emergency Physicians
N/A/414 N/A Registry Process Effective Clinical Care Evaluation or Interview for Risk of Opioid Misuse
  • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record
American Academy of Neurology
! N/A/415 N/A Claims, Registry Process Efficiency and Cost Reduction Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
  • Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.
American College of Emergency Physicians
!! N/A/416 N/A Claims, Registry Efficiency Efficiency and Cost Reduction Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years
  • Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network prediction rules for traumatic brain injury
American College of Emergency Physicians
7. General Practice/Family Medicine
* § ! 0059/001 122v4 Claims, Registry, EHR Intermediate Outcome Effective Clinical Care Diabetes: Hemoglobin A1c Poor Control
  • Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
National Committee for Quality Assurance
§ 0081/005 135v4 Registry, EHR Process Effective Clinical Care Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
American Medical Association- Physician Consortium for Performance/ American College of Cardiology Foundation/American Heart Association
105/009 128v4 EHR Process Effective Clinical Care Anti-Depressant Medication Management
  • Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment
  • Two rates are reported
    • a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks)
    • b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
National Committee for Quality Assurance/American Heart Association
! N/A/050 N/A Claims, Registry Process Person and Caregiver-Centered Experience and Outcomes Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
  • Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
National Committee for Quality Assurance/American Medical Association- Physician Consortium for Performance Improvement
!! 0069/065 154v4 Registry, EHR Process Efficiency and Cost Reduction Appropriate Treatment for Children with Upper Respiratory Infection (URI)
  • Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode
National Committee for Quality Assurance
* !! N/A/066 146v4 Registry, EHR Process Efficiency and Cost Reduction Appropriate Testing for Children with Pharyngitis
  • Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode
National Committee for Quality Assurance
!! 0654/093 N/A Claims, Registry Process Efficiency and Cost Reduction Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
  • Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
American Academy of Otolaryngology-Head and Neck Surgery
! N/A/109 N/A Claims, Registry Process Person and Caregiver-Centered Experience and Outcomes Osteoarthritis (OA): Function and Pain Assessment
  • Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
American Academy of Orthopedic Surgeons
* § 2372/112 125v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Breast Cancer Screening
  • Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer
National Committee for Quality Assurance
§ 0034/113 130v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Colorectal Cancer Screening
  • Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer
National Committee for Quality Assurance
§ !! 0058/116 N/A Registry Process Efficiency and Cost Reduction Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use
  • Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode
National Committee for Quality Assurance
§ 0055/117 131v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Diabetes: Eye Exam
  • Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period
National Committee for Quality Assurance
* 0418/134 2v5 Claims, Web Interface, Registry, EHR Process Community/ Population Health Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow- up plan is documented on the date of the positive screen
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
! 0101/154 N/A Claims, Registry Process Patient Safety Falls: Risk Assessment
  • Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
! 0101/155 N/A Claims, Registry Process Communication and Care Coordination Falls: Plan of Care
  • Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
! N/A/181 N/A Claims, Registry Process Patient Safety Elder Maltreatment Screen and Follow-Up Plan
  • Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
* § 0068/204 164v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
  • Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period
National Committee for Quality Assurance
§ !! 0052/312 166v5 Web Interface, EHR Process Efficiency and Cost Reduction Use of Imaging Studies for Low Back Pain
  • Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis
National Committee for Quality Assurance
§ 1525/326 N/A Claims, Registry Process Effective Clinical Care Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
  • Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
!! N/A/331 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
  • Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/332 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
  • Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/333 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
  • Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/334 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
  • Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
N/A/337 N/A Registry Process Effective Clinical Care Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
  • Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test
American Academy of Dermatology
* § ! 2082/338 N/A Registry Outcome Effective Clinical Care HIV Viral Load Suppression
  • The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year
Health Resources and Services Administration
! N/A/342 N/A Registry Outcome Person and Caregiver-Centered Experience and Outcomes Pain Brought Under Control Within 48 Hours
  • Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours
National Hospice and Palliative Care Organization
N/A/387 N/A Registry Process Effective Clinical Care Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
  • Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period
American Medical Association- Physician Consortium for Performance Improvement
1407/394 N/A Registry Process Community/ Population Health Immunizations for Adolescents
  • The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday
National Committee for Quality Assurance
! N/A/398 N/A Registry Outcome Effective Clinical Care Optimal Asthma Control
  • Patients ages 5-50 (pediatrics ages 5-17) whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools
Minnesota Community Measurement
§ N/A/400 N/A Registry Process Effective Clinical Care One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
  • Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received a one-time screening for HCV infection
American Medical Association- Physician Consortium for Performance Improvement
§ N/A/401 N/A Registry Process Effective Clinical Care Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
  • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period
American Medical Association- Physician Consortium for Performance Improvement/ American Gastroenterological Association
N/A/408 N/A Registry Process Effective Clinical Care Opioid Therapy Follow-up Evaluation
  • All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
American Academy of Neurology
N/A/412 N/A Registry Process Effective Clinical Care Documentation of Signed Opioid Treatment Agreement
  • All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
American Academy of Neurology
N/A/414 N/A Registry Process Effective Clinical Care Evaluation or Interview for Risk of Opioid Misuse
  • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record
American Academy of Neurology
0053/418 N/A Claims, Registry Process Effective Clinical Care Osteoporosis Management in Women Who Had a Fracture
  • The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis.
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
N/A/438 N/A Web Interface, Registry Process Effective Clinical Care Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period:
    • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
    • Adults aged ≥21 years with a fasting or direct low- density lipoprotein cholesterol (LDL-C) level ≥ 190mg/dL; OR
    • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
8. Internal Medicine
* § ! 0059/001 122v4 Claims, Web Interface, Registry, EHR Intermediate Outcome Effective Clinical Care Diabetes: Hemoglobin A1c Poor Control
  • Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
National Committee for Quality Assurance
§ 0081/005 135v4 Registry, EHR Process Effective Clinical Care Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
American Medical Association- Physician Consortium for Performance Improvement/American College of Cardiology Foundation
105/009 128v4 EHR Process Effective Clinical Care Anti-Depressant Medication Management
  • Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported:
    • a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks)
    • b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
National Committee for Quality Assurance/American Heart Association
! N/A/050 N/A Claims, Registry Process Person and Caregiver Centered Experience and Outcomes Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
  • Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
National Committee for Quality Assurance/American Medical Association- Physician Consortium for Performance Improvement
! N/A/109 N/A Claims, Registry Process Person and Caregiver Centered Experience and Outcomes Osteoarthritis (OA): Function and Pain Assessment
  • Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
American Academy of Orthopedic Surgeons
* § 2372/112 125v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Breast Cancer Screening
  • Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer
National Committee for Quality Assurance
§ 0034/113 130v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Colorectal Cancer Screening
  • Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer
National Committee for Quality Assurance
§ !! 0058/116 N/A Registry Process Efficiency and Cost Reduction Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use
  • Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode
National Committee for Quality Assurance
§ 0055/117 131v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Diabetes: Eye Exam
  • Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period
National Committee for Quality Assurance
* 0418/134 2v5 Claims, Web Interface, Registry, EHR Process Community/ Population Health Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
! 0101/154 N/A Claims, Registry Process Patient Safety Falls: Risk Assessment
  • Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
! 0101/155 N/A Claims, Registry Process Communication and Care Coordination Falls: Plan of Care
  • Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
* § 0056/163 123v4 EHR Process Effective Clinical Care Comprehensive Diabetes Care: Foot Exam
  • The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year
National Committee for Quality Assurance
! N/A/181 N/A Claims, Registry Process Patient Safety Elder Maltreatment Screen and Follow-Up Plan
  • Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
* § 0068/204 164v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
  • Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period
National Committee for Quality Assurance
§ 1525/326 N/A Claims, Registry Process Effective Clinical Care Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
  • Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high- risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism
American College of Cardiology/ American Heart Association/ American Medical Association- Physician Consortium for Performance Improvement
!! N/A/331 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
  • Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/332 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
  • Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/333 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
  • Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
!! N/A/334 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
  • Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis
American Academy of Otolaryngology-Head and Neck Surgery
N/A/387 N/A Registry Process Effective Clinical Care Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
  • Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period
American Medical Association- Physician Consortium for Performance Improvement
§ N/A/400 N/A Registry Process Effective Clinical Care One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
  • Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received a one-time screening for HCV infection
American Medical Association- Physician Consortium for Performance Improvement
§ N/A/401 N/A Registry Process Effective Clinical Care Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
  • Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period. This measure was finalized for inclusion in 2015 PQRS in the CY 2014 PFS Final Rule (see Table 53 at 79 FR 67814)
American Medical Association- Physician Consortium for Performance Improvement/ American Gastroenterological Association
N/A/408 N/A Registry Process Effective Clinical Care Opioid Therapy Follow-up Evaluation
  • All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
American Academy of Neurology
N/A/412 N/A Registry Process Effective Clinical Care Documentation of Signed Opioid Treatment Agreement
  • All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
American Academy of Neurology
N/A/414 N/A Registry Process Effective Clinical Care Evaluation or Interview for Risk of Opioid Misuse
  • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record
American Academy of Neurology
0053/418 N/A Claims, Registry Process Effective Clinical Care Osteoporosis Management in Women Who Had a Fracture
  • The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
9. Obstetrics/ Gynecology
N/A/048 N/A Claims, Registry Process Effective Clinical Care Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
  • Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
! N/A/050 N/A Claims, Registry Process Person and Caregiver-Centered Experience and Outcomes Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
  • Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
  • National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    ! N/A/265 N/A Registry Process Communication and Care Coordination Biopsy Follow-Up
  • Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
  • American Academy of Dermatology
    0053/418 N/A Claims, Registry Process Effective Clinical Care Osteoporosis Management in Women Who Had a Fracture
  • The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis
  • National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    ! 2063/422 N/A Claims, Registry Process Patient Safety Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
  • Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
  • American Urogynecologic Society
    ! N/A/432 N/A Registry Outcome Patient Safety Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
  • Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery
  • American Urogynecologic Society
    ! N/A/433 N/A Registry Outcome Patient Safety Proportion of Patients Sustaining a Major Viscus Injury at the Time of Any Pelvic Organ Prolapse Repair
  • Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscus at the time of index surgery that is recognized intraoperative or within 1 month after surgery
  • American Urogynecologic Society
    ! N/A/434 N/A Registry Outcome Patient Safety Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair
  • Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery
  • American Urogynecologic Society
    * § 0032/309 124v4 EHR Process Effective Clinical Care Cervical Cancer Screening
  • Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
    • Women age 21–64 who had cervical cytology performed every 3 years
    • Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
  • National Committee for Quality Assurance
    + § 1395/New N/A Registry Process Community/ Population Health Chlamydia Screening and Follow-up
    • The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow- up
    National Committee for Quality Assurance
    * § 2372/112 125v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Breast Cancer Screening
    • Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer
    National Committee for Quality Assurance
    + § ! 0567/New N/A Registry Process Patient Safety Appropriate Work Up Prior to Endometrial Ablation Procedure
    • To ensure that all women have endometrial sampling performed before undergoing an endometrial ablation
    Health Benchmarks-IMS Health
    + § !! N/A/New N/A Registry Process Patient Safety Non-recommended Cervical Cancer Screening in Adolescent Females
    • The percentage of adolescent females 16–20 years of age unnecessarily screened for cervical cancer
    National Committee for Quality Assurance
    0033/310 153v4 EHR Process Community/ Population Health Chlamydia Screening for Women
    • Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
    National Committee for Quality Assurance
    10. Ophthalmology
    0086/012 143v4 Claims, Registry, EHR Process Effective Clinical Care Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
    • Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months
    American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    0087/014 N/A Claims, Registry Process Effective Clinical Care Age-Related Macular Degeneration (AMD): Dilated Macular Examination
    • Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months
    American Academy of Ophthalmology
    0088/018 167v4 EHR Process Effective Clinical Care Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
    • Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0089/019 124v4 Claims, Registry, EHR Process Communication and Care Coordination Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
    • Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    § 0055/117 131v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Diabetes: Eye Exam
    • Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period
    National Committee for Quality Assurance
    0566/140 N/A Claims,Registry Process Effective Clinical Care Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
    • Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD
    American Academy of Ophthalmology
    ! 0563/141 N/A Claims,Registry Outcome Communication and Care Coordination Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
    • Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months
    American Academy of Ophthalmology
    ! 0565/191 133v4 Registry, EHR Outcome Effective Clinical Care Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
    • Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0564/192 132v4 Registry, EHR Outcome Patient Safety Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
    • Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 1536/303 N/A Registry Outcome Person Caregiver- Centered Experience and Outcomes Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
    • Percentage of patients aged 18 years and older in sample who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post- operative visual function survey
    American Academy of Ophthalmology
    ! N/A/304 N/A Registry Outcome Person Caregiver- Centered Experience and Outcomes Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
    • Percentage of patients aged 18 years and older in sample who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey
    American Academy of Ophthalmology
    ! N/A/384 N/A Registry Outcome Effective Clinical Care Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
    • Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.
    American Academy of Ophthalmology
    ! N/A/385 N/A Registry Outcome Effective Clinical Care Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
    • Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye
    American Academy of Ophthalmology/ The Australian Council on Healthcare Standards
    ! N/A/388 N/A Registry Outcome Patient Safety Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy
    • Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy
    American Academy of Ophthalmology/ American College of Healthcare Sciences
    ! N/A/389 N/A Registry Outcome Effective Clinical Care Cataract Surgery: Difference Between Planned and Final Refraction
    • Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.
    American Academy of Ophthalmology/ American College of Healthcare Sciences
    11. Orthopedic Surgery
    !! 0268/021 N/A Claims, Registry Process Patient Safety Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
    • Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis.
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0239/023 N/A Claims, Registry Process Patient Safety Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
    • Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! N/A/109 N/A Claims, Registry Process Person and Caregiver- Centered Experience and Outcomes Osteoarthritis (OA): Function and Pain Assessment
    • Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
    American Academy of Orthopedic Surgeons
    N/A/178 N/A Registry, Measures Group Process Effective Clinical Care Rheumatoid Arthritis (RA): Functional Status Assessment
    • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months
    American College of Rheumatology
    * N/A/179 N/A Registry Process Effective Clinical Care Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
    • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months
    American College of Rheumatology
    * N/A/180 N/A Registry Process Effective Clinical Care Rheumatoid Arthritis (RA): Glucocorticoid Management
    • Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months
    American College of Rheumatology
    § !! 0052/312 166v5 Web Interface, EHR Process Efficiency and Cost Reduction Use of Imaging Studies for Low Back Pain
    • Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis
    National Committee for Quality Assurance
    * ! N/A/350 N/A Registry Process Communication and Care Coordination Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
    • Percentage of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. Nonsteroidal anti- inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure
    American Association of Hip and Knee Surgeons
    * ! N/A/351 N/A Registry Process Patient Safety Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
    • Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)
    American Association of Hip and Knee Surgeons
    * ! N/A/352 N/A Registry Process Patient Safety Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
    • Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
    American Association of Hip and Knee Surgeons
    * ! N/A/353 N/A Registry Process Patient Safety Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
    • Percentage of patients regardless of age or gender undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant
    American Association of Hip and Knee Surgeons
    ! N/A/358 N/A Registry, Measures Group Process Person and Caregiver- Centered Experience and Outcomes Patient-Centered Surgical Risk Assessment and Communication
    • Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
    American Association of Hip and Knee Surgeons
    * ! N/A/375 N/A Measures Group Process Person and Caregiver- Centered Experience and Outcomes Functional Status Assessment for Total Knee Replacement
    • Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments
    Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
    * ! N/A/376 N/A EHR Process Person and Caregiver- Centered Experience and Outcomes Functional Status Assessment for Total Hip Replacement
    • Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments
    Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
    12. Otolaryngology
    !! 0268/021 N/A Claims, Registry Process Patient Safety Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
    • Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0239/023 N/A Claims, Registry Process Patient Safety Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
    • Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    !! 0653/091 N/A Claims, Registry Process Effective Clinical Care Acute Otitis Externa (AOE): Topical Therapy
    • Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations
    American Academy of Otolaryngology-Head and Neck Surgery
    !! 0654/093 N/A Claims, Registry Process Efficiency and Cost Reduction Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
    • Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
    American Academy of Otolaryngology-Head and Neck Surgery
    !! N/A/331 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
    • Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms
    American Academy of Otolaryngology-Head and Neck Surgery
    !! N/A/332 N/A Registry Process Efficiency and Cost Reduction Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
    • Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis
    American Academy of Otolaryngology-Head and Neck Surgery
    !! N/A/333 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
    • Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
    American Academy of Otolaryngology-Head and Neck Surgery
    !! N/A/334 N/A Registry Efficiency Efficiency and Cost Reduction Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
    • Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis
    American Academy of Otolaryngology-Head and Neck Surgery
    * ! N/A/357 N/A Registry Outcome Effective Clinical Care Surgical Site Infection (SSI)
    • Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
    American College of Surgeons
    ! N/A/358 N/A Registry Process Person and Caregiver- Centered Experience and Outcomes Patient-Centered Surgical Risk Assessment and Communication
    • Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
    American College of Surgeons
    13. Pathology
    0391/099 N/A Claims, Registry Process Effective Clinical Care Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
    • Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade
    College of American Pathologists
    0392/100 N/A Claims, Registry Process Effective Clinical Care Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
    • Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade
    College of American Pathologists
    1854/249 N/A Claims, Registry Structure Effective Clinical Care Barrett's Esophagus
    • Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia
    College of American Pathologists
    § 1853/250 N/A Claims, Registry Structure Effective Clinical Care Radical Prostatectomy Pathology Reporting
    • Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status
    College of American Pathologists
    1855/251 N/A Claims, Registry Structure Effective Clinical Care Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients
    • This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer
    College of American Pathologists
    ! N/A/395 N/A Claims, Registry Process Communication and Care Coordination Lung Cancer Reporting (Biopsy/Cytology Specimens)
    • Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary nonsmall cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report
    College of American Pathologists
    ! N/A/396 N/A Claims, Registry Process Communication and Care Coordination Lung Cancer Reporting (Resection Specimens)
    • Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type
    College of American Pathologists
    ! N/A/397 N/A Claims, Registry Process Communication and Care Coordination Melanoma Reporting
    • Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate
    College of American Pathologists
    14. Pediatrics
    !! 0069/065 154v4 Registry, EHR Process Efficiency and Cost Reduction Appropriate Treatment for Children with Upper Respiratory Infection (URI)
    • Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.
    National Committee for Quality Assurance
    * !! N/A/066 146v4 Registry, EHR Process Efficiency and Cost Reduction Appropriate Testing for Children with Pharyngitis
    • Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.
    National Committee for Quality Assurance
    !! 0653/091 N/A Claims, Registry Process Effective Clinical Care Acute Otitis External (AOE): Topical Therapy
    • Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations
    American Academy of Otolaryngology-Head and Neck Surgery
    !! 0654/093 N/A Claims, Registry Process Efficiency and Cost Reduction Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
    • Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
    American Academy of Otolaryngology-Head and Neck Surgery
    0041/110 147v5 Claims, Web Interface, Registry, EHR Process Community/ Population Health Preventive Care and Screening: Influenza Immunization
    • Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
    American Medical Association- Physician Consortium for Performance Improvement
    * 0418/134 2v5 Claims, Web Interface, Registry, EHR Process Community/ Population Health Preventive Care and Screening: Screening for Depression and Follow-Up Plan
    • Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
    Centers for Medicare & Medicaid Services/'Mathematica/Quality Insights of Pennsylvania
    * § 0405/160 2v5 EHR Process Effective Clinical Care HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
    • Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis
    National Committee for Quality Assurance
    § 0409/205 N/A Registry Process Effective Clinical Care HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
    • Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection
    National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    0024/239 155v4 EHR Process Community/ Population Health Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
    • Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.
      • Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
      • Percentage of patients with counseling for nutrition
      • Percentage of patients with counseling for physical activity
    National Committee for Quality Assurance
    0038/240 117v4 EHR Process Community/ Population Health Childhood Immunization Status
    • Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday
    National Committee for Quality Assurance
    15. Physical Medicine
    ! N/A/109 N/A Claims, Registry Process Person and Caregiver- Centered Experience and Outcomes Osteoarthritis (OA): Function and Pain Assessment
    • Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
    American Academy of Orthopedic Surgeons
    ! 0420/131 N/A Claims, Registry Process Communication and Care Coordination Pain Assessment and Follow-Up
    • Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
    Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
    ! 2624/182 N/A Claims, Registry Process Communication and Care Coordination Functional Outcome Assessment
    • Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
    Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
    § !! 0052/312 166v5 Web Interface, EHR Process Efficiency and Cost Reduction Use of Imaging Studies for Low Back Pain
    • Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis
    National Committee for Quality Assurance
    N/A/408 N/A Registry Process Effective Clinical Care Opioid Therapy Follow-up Evaluation
    • All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
    American Academy of Neurology
    N/A/412 N/A Registry Process Effective Clinical Care Documentation of Signed Opioid Treatment Agreement
    • All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
    American Academy of Neurology
    N/A/414 N/A Registry Process Effective Clinical Care Evaluation or Interview for Risk of Opioid Misuse
    • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record
    American Academy of Neurology
    16. Plastic Surgery
    !! 0268/021 N/A Claims, Registry Process Patient Safety Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
    • Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0239/023 N/A Claims, Registry Process Patient Safety Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
    • Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! N/A/358 N/A Registry Process Person and Caregiver-Centered Experience and Outcomes Patient-Centered Surgical Risk Assessment and Communication
    • Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
    American College of Surgeons
    17. Preventative Medicine
    * § ! 0059/001 122v4 Claims, Web Interface, Registry, EHR Intermediate Outcome Effective Clinical Care Diabetes: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
    • Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
    National Committee for Quality Assurance
    ! 0045/024 N/A Claims, Registry Process Communication and Care Coordination Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older
    • Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on- going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication
    National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    0046/039 N/A Claims, Registry Process Effective Clinical Care Screening for Osteoporosis for Women Aged 65-85 Years of Age
    • Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis
    National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    N/A/048 N/A Claims, Registry Process Effective Clinical Care Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
    • Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
    National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    ! N/A/109 N/A Claims, Registry Process Person and Caregiver- Centered Experience and Outcomes Osteoarthritis (OA): Function and Pain Assessment
    • Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
    American Academy of Orthopedic Surgeons
    0041/110 147v5 Claims, Web Interface, Registry, EHR Process Community/ Population Health Preventive Care and Screening: Influenza Immunization
    • Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
    American Medical Association- Physician Consortium for Performance Improvement
    0043/111 127v4 Claims, Web Interface, Registry, EHR Process Community/ Population Health Pneumonia Vaccination Status for Older Adults
    • Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
    National Committee for Quality Assurance
    * § 2372/112 125v4 Claims, Web Interface, Registry, EHR Process Effective Clinical Care Breast Cancer Screening
    • Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer
    National Committee for Quality Assurance
    18. Neurology
    0325/032 N/A Claims, Registry Process Effective Clinical Care Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
    • Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an antithrombotic at discharge
    American Academy of Neurology
    * 1814/268 N/A Claims, Registry Process Effective Clinical Care Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
    • All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year
    American Academy of Neurology
    N/A/281 149v4 EHR Process Effective Clinical Care Dementia: Cognitive Assessment
    • Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period
    American Medical Association- Physician Consortium for Performance Improvement
    * N/A/282 N/A Registry Process Effective Clinical Care Dementia: Functional Status Assessment
    • Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * N/A/283 N/A Registry Process Effective Clinical Care Dementia: Neuropsychiatric Symptom Assessment
    • Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * N/A/284 N/A Registry Process Effective Clinical Care Dementia: Management of Neuropsychiatric Symptoms
    • Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * ! N/A/286 N/A Registry Process Patient Safety Dementia: Counseling Regarding Safety Concerns
    • Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * ! N/A/288 N/A Registry Process Communication and Care Coordination Dementia: Caregiver Education and Support
    • Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * N/A/290 N/A Registry Process Effective Clinical Care Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment:
    • All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric disorders or disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at least annually
    American Academy of Neurology
    * N/A/291 N/A Registry Process Effective Clinical Care Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
    • All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction at least annually
    American Academy of Neurology
    * ! N/A/293 N/A Registry Process Communication and Care Coordination Parkinson’s Disease: Rehabilitative Therapy Options
    • All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed at least annually
    American Academy of Neurology
    * ! N/A/294 N/A Registry Process Communication and Care Coordination Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
    • All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually
    American Academy of Neurology
    * ! N/A/386 N/A Registry Process Person and Caregiver- Centered Experience and Outcomes Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
    • Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually
    American Academy of Neurology
    N/A/408 N/A Registry Process Effective Clinical Care Opioid Therapy Follow-up Evaluation
    • All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
    American Academy of Neurology
    N/A/412 N/A Registry Process Effective Clinical Care Documentation of Signed Opioid Treatment Agreement
    • All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
    American Academy of Neurology
    N/A/414 N/A Registry Process Effective Clinical Care Evaluation or Interview for Risk of Opioid Misuse
    • All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record
    American Academy of Neurology
    !! N/A/419 N/A Claims, Registry Efficiency Efficiency and Cost Reduction Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination
    • Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered
    American Academy of Neurology
    ! N/A/435 N/A Claims, Registry Outcome Effective Clinical Care Quality Of Life Assessment For Patients With Primary Headache Disorders
    • Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved
    American Academy of Neurology
    19. Mental/Behavioral Health
    105/009 128v4 EHR Process Effective Clinical Care Anti-Depressant Medication Management
    • Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported:
      • a. Percentage of patients who remained on an anti depressant medication for at least 84 days (12 weeks)
      • b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
    National Committee for Quality Assurance/American Heart Association
    * 0418/134 N/A Claims, Web Interface, Registry, EHR, Measures Groups Process Community /Population Health Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
    • Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
    Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
    ! N/A/181 N/A Claims, Registry Process Patient Safety Elder Maltreatment Screen and Follow-Up Plan
    • Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
    Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
    N/A/281 149v4 EHR Process Effective Clinical Care Dementia: Cognitive Assessment
    • Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period
    American Medical Association- Physician Consortium for Performance Improvement
    * N/A/282 N/A Registry Process Effective Clinical Care Dementia: Functional Status Assessment
    • Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * N/A/283 N/A Registry Process Effective Clinical Care Dementia: Neuropsychiatric Symptom Assessment
    • Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * N/A/284 N/A Registry Process Effective Clinical Care Dementia: Management of Neuropsychiatric Symptoms
    • Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * ! N/A/286 N/A Registry Process Patient Safety Dementia: Counseling Regarding Safety Concerns
    • Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    * ! N/A/288 N/A Registry Process Communication and Care Coordination Dementia: Caregiver Education and Support
    • Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period
    American Academy of Neurology/ American Psychiatric Association
    ! N/A/325 N/A Registry Process Communication and Care Coordination Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
    • Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
    American Psychiatric Association/ American Medical Association- Physician Consortium for Performance Improvement
    ! 1879/383 N/A Registry Intermediate Outcome Patient Safety Adherence to Antipsychotic Medications for Individuals with Schizophrenia
    • Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medication during the measurement period (12 consecutive months)
    Health Services Advisory Group/ Centers for Medicare & Medicaid Services
    ! 0576/391 N/A Registry Process Communication and Care Coordination Follow-up After Hospitalization for Mental Illness (FUH)
    • The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:
      • The percentage of discharges for which the patient received follow-up within 30 days of discharge
      • The percentage of discharges for which the patient received follow-up within 7 days of discharge
    National Committee for Quality Assurance
    20. Radiology
    !! N/A/145 N/A Registry Process Patient Safety Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
    • Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)
    American College of Radiology/ American Medical Association- Physician Consortium for Performance Improvement
    ! 0508/146 N/A Claims, Registry Process Efficiency and Cost Reduction Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening
    • Percentage of final reports for screening mammograms that are classified as “probably benign”
    American College of Radiology/ American Medical Association- Physician Consortium for Performance Improvement
    ! N/A/147 N/A Claims, Registry Process Communication and Care Coordination Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
    • Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed
    Society of Nuclear Medicine and Molecular Imaging / American Medical Association- Physician Consortium for Performance Improvement
    0507/195 N/A Claims, Registry Process Effective Clinical Care Radiology: Stenosis Measurement in Carotid Imaging Reports
    • Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement
    American College of Radiology/ American Medical Association- Physician Consortium for Performance Improvement
    0509/225 N/A Claims, Registry Structure Communication and Care Coordination Radiology: Reminder System for Screening Mammograms
    • Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram
    American College of Radiology/ American Medical Association- Physician Consortium for Performance Improvement
    * ! N/A/359 N/A Registry Process Communication and Care Coordination Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging
    • Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems
    American College of Radiology
    * !! N/A/360 N/A Registry Process Patient Safety Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
    • Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.
    American College of Radiology
    * ! N/A/361 N/A Registry Structure Patient Safety Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
    • Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements
    American College of Radiology
    * ! N/A/362 N/A Registry Structure Communication and Care Coordination Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
    • Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study. This measure was finalized for inclusion in 2014 PQRS in the CY 2013 PFS Final Rule (see Table 52 at 78 FR 74667)
    American College of Radiology
    * ! N/A/363 N/A Registry Process Communication and Care Coordination Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive
    • Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed
    American College of Radiology
    * !! N/A/364 N/A Registry Process Communication and Care Coordination Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
    • Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
    American College of Radiology
    N/A/405 N/A Claims, Registry Process Effective Clinical Care Appropriate Follow-up Imaging for Incidental Abdominal Lesions
    • Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended:
      • Liver lesion ≤ 0.5 cm
      • Cystic kidney lesion < 1.0 cm
      • Adrenal lesion ≤ 1.0 cm
    American College of Radiology
    !! N/A/406 N/A Claims, Registry Process Effective Clinical Care Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients
    • Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended
    American College of Radiology
    N/A/436 N/A Claims, Registry Process Effective Clinical Care Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
    • Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used:
      • Automated exposure control
      • Adjustment of the mA and/or kV according to patient size
      • Use of iterative reconstruction technique
    American College of Radiology/ American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! N/A/259 N/A Registry Outcome Patient Safety Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)
    • Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post- operative day #2)
    Society for Vascular Surgeons
    ! N/A/265 N/A Registry Process Communication and Care Coordination Biopsy Follow-Up
    • Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
    American Academy of Dermatology
    ! N/A/344 N/A Registry Outcome Effective Clinical Care Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
    • Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2
    Society for Vascular Surgeons
    ! N/A/345 N/A Registry Outcome Effective Clinical Care Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
    • Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital
    Society for Vascular Surgeons
    * § !! 0389/102 129v5 Registry, EHR Process Efficiency and Cost Reduction Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
    • Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
    American Medical Association- Physician Consortium for Performance Improvement
    § ! 0384/143 157v4 Registry, EHR Process Person and Caregiver Centered Experience and Outcome Oncology: Medical and Radiation – Pain Intensity Quantified
    • Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified
    American Medical Association- Physician Consortium for Performance Improvement
    ! 0383/144 N/A Registry Process Person and Caregiver Centered Experience and Outcome Oncology: Medical and Radiation – Plan of Care for Pain
    • Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain
    American Society of Clinical Oncology
    !! 0382/156 N/A Claims, Registry Process Patient Safety Oncology: Radiation Dose Limits to Normal Tissues
    • Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
    American Society of Radiation Oncology
    21. Surgery
    ! N/A/258 N/A Registry Outcome Patient Safety Rate of Open Elective Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post- Operative Day #7)
    • Percent of patients undergoing open repair of small or moderate sized non-ruptured abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)
    Society for Vascular Surgeons
    ! N/A/259 N/A Registry Outcome Patient Safety Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged at Home by Post-Operative Day #2)
    • Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post- operative day #2)
    Society for Vascular Surgeons
    ! N/A/260 N/A Registry Outcome Patient Safety Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
    • Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2)
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! N/A/344 N/A Registry Outcome Effective Clinical Care Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
    • Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2
    Society for Vascular Surgeons
    ! N/A/345 N/A Registry Outcome Effective Clinical Care Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
    • Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital
    Society for Vascular Surgeons
    ! 1534/347 N/A Registry Outcome Patient Safety Rate of Endovascular Aneurysm Repair (EVAR of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital
    • Percent of patients undergoing endovascular repair of small or moderate abdominal aortic aneurysms (AAA) who die while in the hospital
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    !! 0268/021 N/A Claims, Registry Process Patient Safety Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalasporin
    • Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, which had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0271/022 N/A Claims, Registry Process Patient Safety Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)
    • Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    ! 0239/023 N/A Claims, Registry Process Patient Safety Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
    • Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
    American Medical Association- Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
    * ! N/A/354 N/A Registry Outcome Patient Safety Anastomotic Leak Intervention
    • Percentage patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery
    American College of Surgeons
    * ! N/A/355 N/A Registry Outcome Patient Safety Unplanned Reoperation within the 30 Day Postoperative Period
    • Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period
    American College of Surgeons
    * ! N/A/356 N/A Registry Outcome Effective Clinical Care Unplanned Hospital Readmission within 30 Days of Principal Procedure
    • Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
    American College of Surgeons
    * ! N/A/357 N/A Registry Outcome Effective Clinical Care Surgical Site Infection (SSI)
    • Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
    American College of Surgeons
    ! N/A/358 N/A Registry Process Person and Caregiver- Centered Experience and Outcomes Patient-Centered Surgical Risk Assessment and Communication
    • Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
    American College of Surgeons
    22. Thoracic Surgery
    !! 0268/021 N/A Claims, Registry Process Patient Safety Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
    • Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis
    American Medical Association- Physician Consortium for Performance/ National Committee for Quality Assurance
    ! 0239/023 N/A Registry Process Patient Safety Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
    • Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
    American Medical Association- Physician Consortium for Performance/ National Committee for Quality Assurance
    ! 0129/164 N/A Registry Outcome Effective Clinical Care Coronary Artery Bypass Graft (CABG): Prolonged Intubation
    • Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours
    American Thoracic Society
    * ! 0130/165 N/A Registry Outcome Effective Clinical Care Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
    • Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention
    American Thoracic Society
    * ! 0131/166 N/A Registry Outcome Effective Clinical Care Coronary Artery Bypass Graft (CABG): Stroke
    • Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours
    American Thoracic Society
    * ! 0114/167 N/A Registry Outcome Effective Clinical Care Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
    • Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis
    American Thoracic Society
    * ! 0115/168 N/A Registry Outcome Effective Clinical Care Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
    • Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason
    Society of Thoracic Surgeons
    * ! N/A/357 N/A Registry Outcome Effective Clinical Care Surgical Site Infection (SSI)
    • Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
    American College of Surgeons
    ! N/A/358 N/A Registry Process Person and Caregiver-Centered Experience and Outcomes Patient-Centered Surgical Risk Assessment and Communication
    • Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
    American College of Surgeons
    23. Urology
    N/A/048 N/A Claims, Registry Process Effective Clinical Care Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
    • Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
    National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    ! N/A/050 N/A Claims, Registry Process Person and Caregiver - Centered Experience and Outcomes Urinary Incontinence: Assessment of Presence or Absence Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
    • Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
    National Committee for Quality Assurance/ American Medical Association- Physician Consortium for Performance Improvement
    * § !! 0389/102 129v5 Registry, EHR Process Efficiency and Cost Reduction Prostate Cancer: Avoidance of Overuse of Bone Scan for staging Low Risk Prostate Cancer Patients
    • Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
    American Medical Association- Physician Consortium for Performance Improvement
    0390/104 N/A Registry Process Effective Clinical Care Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or very High Risk Prostate Cancer
    • Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist
    American Medical Association- Physician Consortium for Performance Improvement/American Urological Association Education and Research
    ! N/A/265 N/A Registry Process Communication and Care Coordination Biopsy Follow-Up
    • Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
    American Academy of Dermatology
    * ! N/A/357 N/A Registry Process Effective Clinical Care Surgical Site Infection (SSI)
    • Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
    American College of Surgeons
    ! N/A/358 N/A Registry Process Person and Caregiver- Centered Experience and Outcomes Patient-Centered Surgical Risk Assessment and Communication
    • Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
    American College of Surgeons