[
  {
    "category": "ia",
    "title": "Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record",
    "description": "Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:- Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);- Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or- Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.",
    "measureId": "IA_EPA_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "title": "Use of telehealth services that expand practice access",
    "description": "Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.",
    "measureId": "IA_EPA_2",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "title": "Collection and use of patient experience and satisfaction data on access",
    "description": "Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.",
    "measureId": "IA_EPA_3",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "title": "Additional improvements in access as a result of QIN/QIO TA",
    "description": "As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services or improve care coordination (for example, investment of on-site diabetes educator).",
    "measureId": "IA_EPA_4",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "title": "Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)",
    "description": "User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provide substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.",
    "measureId": "IA_EPA_5",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "expandedPracticeAccess"
  },
  {
    "category": "ia",
    "title": "Anticoagulant Management Improvements",
    "description": "Individual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities:- Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program);- Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;- Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;- For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; or- For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.",
    "measureId": "IA_PM_2",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "RHC, IHS or FQHC quality improvement activities",
    "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting , and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients.  Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.",
    "measureId": "IA_PM_3",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Glycemic management services",
    "description": "For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having: For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that: a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, andb) Is reassessed at least annually.The performance threshold will increase to 75 percent for the second performance year and onward.Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.",
    "measureId": "IA_PM_4",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Engagement of community for health status improvement",
    "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition.  Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity.  QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.",
    "measureId": "IA_PM_5",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Use of toolsets or other resources to close healthcare disparities across communities",
    "description": "Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.",
    "measureId": "IA_PM_6",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Use of QCDR for feedback reports that incorporate population health",
    "description": "Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.",
    "measureId": "IA_PM_7",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Regular Review Practices in Place on Targeted Patient Population Needs",
    "description": "Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.",
    "measureId": "IA_PM_11",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Population empanelment",
    "description": "Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management. Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.",
    "measureId": "IA_PM_12",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Chronic Care and Preventative Care Management for Empaneled Patients",
    "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:- Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;- Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP)93 and the NCQA Heart/Stroke Recognition Program (HSRP)94;- Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;- Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;- Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/orUse reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.",
    "measureId": "IA_PM_13",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients",
    "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/orUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.",
    "measureId": "IA_PM_14",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Implementation of episodic care management practice improvements",
    "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/orManaging care intensively through new diagnoses, injuries and exacerbations of illness.",
    "measureId": "IA_PM_15",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Implementation of medication management practice improvements",
    "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/orConduct periodic, structured medication reviews.",
    "measureId": "IA_PM_16",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Participation in Population Health Research",
    "description": "Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.",
    "measureId": "IA_PM_17",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Provide Clinical-Community Linkages",
    "description": "Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency.  This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes.  An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.",
    "measureId": "IA_PM_18",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Glycemic Screening Services",
    "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.",
    "measureId": "IA_PM_19",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Glycemic Referring Services",
    "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.",
    "measureId": "IA_PM_20",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Advance Care Planning",
    "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.",
    "measureId": "IA_PM_21",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "populationManagement"
  },
  {
    "category": "ia",
    "title": "Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop",
    "description": "Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.",
    "measureId": "IA_CC_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Implementation of improvements that contribute to more timely communication of test results",
    "description": "Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.",
    "measureId": "IA_CC_2",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Regular training in care coordination",
    "description": "Implementation of regular care coordination training.",
    "measureId": "IA_CC_7",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Implementation of documentation improvements for practice/process improvements",
    "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).",
    "measureId": "IA_CC_8",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Implementation of practices/processes for developing regular individual care plans",
    "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient's goals and priorities, as well as desired outcomes of care.",
    "measureId": "IA_CC_9",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Care transition documentation practice improvements",
    "description": "In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient's preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.",
    "measureId": "IA_CC_10",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Care transition standard operational improvements",
    "description": "Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/orPartner with community or hospital-based transitional care services.",
    "measureId": "IA_CC_11",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Care coordination agreements that promote improvements in patient tracking across settings",
    "description": "Establish effective care coordination and active referral management that could include one or more of the following:Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/orSystematically integrate information from referrals into the plan of care.",
    "measureId": "IA_CC_12",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Practice Improvements for Bilateral Exchange of Patient Information",
    "description": "Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following: - Participate in a Health Information Exchange if available; and/or - Use structured referral notes.",
    "measureId": "IA_CC_13",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Practice Improvements that Engage Community Resources to Support Patient Health Goals",
    "description": "Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: - Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.- Including through the use of tools that facilitate electronic communication between settings;- Screen patients for health-harming legal needs;- Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or- Provide a guide to available community resources.",
    "measureId": "IA_CC_14",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "PSH Care Coordination",
    "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH.  The clinician must perform one or more of the following care coordination activities:- Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;- Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;- Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or- Implement processes to ensure effective communications and education of patients’ post-discharge instructions.",
    "measureId": "IA_CC_15",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients",
    "description": "The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.",
    "measureId": "IA_CC_16",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Patient Navigator Program",
    "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.",
    "measureId": "IA_CC_17",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Relationship-Centered Communication",
    "description": "In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan.The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.",
    "measureId": "IA_CC_18",
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.",
    "description": "To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period.  Reporting the PRC modifiers enables the identification of a clinician’s relationship with, and responsibility for, a patient at the time of furnishing an item or service. See the CY 2018 PFS final rule (82 FR 53232 through 53234) for more details on these codes.",
    "measureId": "IA_CC_19",
    "metricType": "boolean",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "careCoordination"
  },
  {
    "category": "ia",
    "title": "Use of certified EHR to capture patient reported outcomes",
    "description": "In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.",
    "measureId": "IA_BE_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Engagement with QIN-QIO to implement self-management training programs",
    "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.",
    "measureId": "IA_BE_3",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Engagement of patients through implementation of improvements in patient portal",
    "description": "To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to:  brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.",
    "measureId": "IA_BE_4",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities",
    "description": "Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities.  For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973",
    "measureId": "IA_BE_5",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement",
    "description": "Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.",
    "measureId": "IA_BE_6",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Participation in a QCDR, that promotes use of patient engagement tools.",
    "description": "Participation in a Qualified Clinical Data Registry (QCDR), that promotes patient engagement, including:- Use of processes and tools that engage patients for adherence to treatment plans;- Implementation of patient self-action plans;- Implementation of shared clinical decision making capabilities; or- Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.",
    "measureId": "IA_BE_7",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.",
    "description": "Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.",
    "measureId": "IA_BE_8",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Use evidence-based decision aids to support shared decision-making.",
    "description": "Use evidence-based decision aids to support shared decision-making.",
    "measureId": "IA_BE_12",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.",
    "description": "Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.",
    "measureId": "IA_BE_13",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Engage Patients and Families to Guide Improvement in the System of Care",
    "description": "Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement.  Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way).  Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.",
    "measureId": "IA_BE_14",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care",
    "description": "Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.",
    "measureId": "IA_BE_15",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Evidenced-based techniques to promote self-management into usual care",
    "description": "Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.",
    "measureId": "IA_BE_16",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Use of tools to assist patient self-management",
    "description": "Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).",
    "measureId": "IA_BE_17",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Provide peer-led support for self-management.",
    "description": "Provide peer-led support for self-management.",
    "measureId": "IA_BE_18",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Use group visits for common chronic conditions (e.g., diabetes).",
    "description": "Use group visits for common chronic conditions (e.g., diabetes).",
    "measureId": "IA_BE_19",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Implementation of condition-specific chronic disease self-management support programs",
    "description": "Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.",
    "measureId": "IA_BE_20",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Improved Practices that Disseminate Appropriate Self-Management Materials",
    "description": "Provide self-management materials at an appropriate literacy level and in an appropriate language.",
    "measureId": "IA_BE_21",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Improved Practices that Engage Patients Pre-Visit",
    "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient's appointment.",
    "measureId": "IA_BE_22",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Integration of patient coaching practices between visits",
    "description": "Provide coaching between visits with follow-up on care plan and goals.",
    "measureId": "IA_BE_23",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Financial Navigation Program",
    "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options.  The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.",
    "measureId": "IA_BE_24",
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Drug Cost Transparency",
    "description": "To receive credit for this improvement activity, MIPS eligible clinicians must attest that their practice provides counseling to patients and/or their caregivers about the costs of drugs and the patients' out-of-pocket costs for the drugs. If appropriate, the clinician must also explore with their patients the availability of alternative drugs and patients' eligibility for patient assistance programs that provide free medications to people who cannot afford to buy their medicine. One source of information for pricing of pharmaceuticals could be a real-time benefit tool (RTBT), which provides to the prescriber, real-time patient-specific formulary and benefit information for drugs, including cost-sharing for a beneficiary. (CMS finalized in the Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out of Pocket Expenses final rule (84 FR 23832, 23883) that beginning January 1, 2021 Medicare Part D plans will be required to implement one or more RTBT(s).)",
    "measureId": "IA_BE_25",
    "metricType": "boolean",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "beneficiaryEngagement"
  },
  {
    "category": "ia",
    "title": "Participation in an AHRQ-listed patient safety organization.",
    "description": "Participation in an AHRQ-listed patient safety organization.",
    "measureId": "IA_PSPA_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Participation in MOC Part IV",
    "description": "In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.",
    "measureId": "IA_PSPA_2",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS or Other Similar Activity",
    "description": "For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS® or the American Board of Family Medicine (ABFM) Performance in Practice Modules.",
    "measureId": "IA_PSPA_3",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Administration of the AHRQ Survey of Patient Safety Culture",
    "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html).Note:  This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.",
    "measureId": "IA_PSPA_4",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Consultation of the Prescription Drug Monitoring Program",
    "description": "Clinicians would attest to reviewing the patients’ history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days.  For the transition year, clinicians would attest to 60 percent review of applicable patient’s history.  For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient’s history performance.",
    "measureId": "IA_PSPA_6",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Use of QCDR data for ongoing practice assessment and improvements",
    "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:- Performance of activities that promote use of standard practices, tools and processes for quality improvement (for example, documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups);- Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);- Use of standardized processes for screening for social determinants of health such as food security, employment, and housing;- Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or- Use of QCDR data for quality improvement such as comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcomes.",
    "measureId": "IA_PSPA_7",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Use of Patient Safety Tools",
    "description": "In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.",
    "measureId": "IA_PSPA_8",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Completion of the AMA STEPS Forward program",
    "description": "Completion of the American Medical Association’s STEPS Forward program.",
    "measureId": "IA_PSPA_9",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments",
    "description": "Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.",
    "measureId": "IA_PSPA_10",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Participation in CAHPS or other supplemental questionnaire",
    "description": "Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).",
    "measureId": "IA_PSPA_11",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Participation in private payer CPIA",
    "description": "Participation in designated private payer clinical practice improvement activities.",
    "measureId": "IA_PSPA_12",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Participation in Joint Commission Evaluation Initiative",
    "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative",
    "measureId": "IA_PSPA_13",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Implementation of an ASP",
    "description": "Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics.  Specific activities may include: - Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.- Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). - Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.- Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. - Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.- Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.- Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. - Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions.  - Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.- Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship guidance",
    "measureId": "IA_PSPA_15",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Use of decision support and standardized treatment protocols",
    "description": "Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.",
    "measureId": "IA_PSPA_16",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Implementation of analytic capabilities to manage total cost of care for practice population",
    "description": "In order to receive credit for this activity, a MIPS eligible clinician must conduct or build the capacity to conduct analytic activities to manage total cost of care for the practice population. Examples of these activities could include:1.)   Train appropriate staff on interpretation of cost and utilization information;2.) Use available data regularly to analyze opportunities to reduce cost through improved care. An example of a platform with the necessary analytic capability to do this is the American Society for Gastrointestinal (GI) Endoscopy's GI Operations Benchmarking Platform.",
    "measureId": "IA_PSPA_17",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Measurement and Improvement at the Practice and Panel Level",
    "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that could include one or more of the following:- Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or - Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.",
    "measureId": "IA_PSPA_18",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes",
    "description": "Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following, such as:- Participation in multisource feedback; - Train all staff in quality improvement methods;- Integrate practice change/quality improvement into staff duties;- Engage all staff in identifying and testing practices changes;- Designate regular team meetings to review data and plan improvement cycles;- Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;- Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;- Participation in Bridges to Excellence;- Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.",
    "measureId": "IA_PSPA_19",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes",
    "description": "Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following:   Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/orIncorporate population health, quality and patient experience metrics in regular reviews of practice performance.",
    "measureId": "IA_PSPA_20",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Implementation of fall screening and assessment programs",
    "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).",
    "measureId": "IA_PSPA_21",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain",
    "description": "Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course Applying CDC's Guideline for Prescribing Opioids that reviews the 2016 Guideline for Prescribing Opioids for Chronic Pain. Note:  This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.",
    "measureId": "IA_PSPA_22",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Completion of CDC Training on Antibiotic Stewardship",
    "description": "Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.",
    "measureId": "IA_PSPA_23",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Cost Display for Laboratory and Radiographic Orders",
    "description": "Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.",
    "measureId": "IA_PSPA_25",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event",
    "description": "A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient's primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.",
    "measureId": "IA_PSPA_26",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Invasive Procedure or Surgery Anticoagulation Medication Management",
    "description": "For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation.  Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)).  An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.",
    "measureId": "IA_PSPA_27",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Completion of an Accredited Safety or Quality Improvement Program",
    "description": "Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:- The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;- The activity must have specific, measurable aim(s) for improvement;- The activity must include interventions intended to result in improvement;- The activity must include data collection and analysis of performance data to assess the impact of the interventions; and- The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).",
    "measureId": "IA_PSPA_28",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Consulting AUC Using Clinical Decision Support when Ordering Advanced",
    "description": "Clinicians attest that they are consulting specified applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018. This activity is for clinicians that are early adopters of the Medicare AUC program (2018 performance year) and for clinicians that begin the Medicare AUC program in future years as specified in our regulation at §414.94.  The AUC program is required under section 218 of the Protecting Access to Medicare Act of 2014.  Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.",
    "measureId": "IA_PSPA_29",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "PCI Bleeding Campaign",
    "description": "Participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI).The program uses a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for PCI patients by implementing quality improvement strategies:- Radial-artery access,- Bivalirudin, and- Use of vascular closure devices.",
    "measureId": "IA_PSPA_30",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Patient Medication Risk Education",
    "description": "In order to receive credit for this activity, MIPS eligible clinicians must provide both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use for patients who are prescribed both benzodiazepines and opioids. Education must be completed for at least 75% of qualifying patients and occur: (1) at the time of initial co-prescribing and again following greater than 6 months of co- prescribing of benzodiazepines and opioids, or (2) at least once per MIPS performance period for patients taking concurrent opioid and benzodiazepine therapy.",
    "measureId": "IA_PSPA_31",
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support",
    "description": "In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain[1] via clinical decision support (CDS).  For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care.  Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.",
    "measureId": "IA_PSPA_32",
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "patientSafetyAndPracticeAssessment"
  },
  {
    "category": "ia",
    "title": "Engagement of New Medicaid Patients and Follow-up",
    "description": "Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare.  A timely manner is defined as within 10 business days for this activity.",
    "measureId": "IA_AHE_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "title": "Promote Use of Patient-Reported Outcome Tools",
    "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.",
    "measureId": "IA_AHE_3",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "title": "MIPS Eligible Clinician Leadership in Clinical Trials or CBPR",
    "description": "MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.",
    "measureId": "IA_AHE_5",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "title": "Provide Education Opportunities for New Clinicians",
    "description": "MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.",
    "measureId": "IA_AHE_6",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "title": "Comprehensive Eye Exams",
    "description": "To receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by any one or more of the following:  - providing literature, - facilitating a conversation about this topic using resources such as the \"Think About Your Eyes\" campaign,  - referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology's EyeCare America and the American Optometric Association's VISION USA, or -  promoting access to vision rehabilitation services as appropriate for individuals with chronic vision impairment.This activity is intended for:- Non-ophthalmologists / optometrists who refer patients to an ophthalmologist/optometrist;- Ophthalmologists/optometrists caring for underserved patients at no cost; or- Any clinician providing literature and/or resources on this topic.This activity must be targeted at underserved and/or high-risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams or vision rehabilitation services.",
    "measureId": "IA_AHE_7",
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "achievingHealthEquity"
  },
  {
    "category": "ia",
    "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.",
    "description": "Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient.  MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.",
    "measureId": "IA_ERP_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "emergencyResponseAndPreparedness"
  },
  {
    "category": "ia",
    "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.",
    "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient.  MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.",
    "measureId": "IA_ERP_2",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "emergencyResponseAndPreparedness"
  },
  {
    "category": "ia",
    "title": "COVID-19 Clinical Data Reporting with or without Clinical Trial",
    "description": "To receive credit for this improvement activity, a MIPS eligible clinician or group must: (1) participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study; or (2) participate in the care of patients diagnosed with COVID-19 and simultaneously submit relevant clinical data to a clinical data registry for ongoing or future COVID-19 research. Data would be submitted to the extent permitted by applicable privacy and security laws. Examples of COVID-19 clinical trials may be found on the U.S. National Library of Medicine website at https://clinicaltrials.gov/ct2/results?cond=COVID-19. In addition, examples of COVID-19 clinical data registries may be found on the National Institute of Health website at https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=COVID19+registries&commit=Search.",
    "measureId": "IA_ERP_3",
    "metricType": "boolean",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "emergencyResponseAndPreparedness"
  },
  {
    "category": "ia",
    "title": "Diabetes screening",
    "description": "Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.",
    "measureId": "IA_BMH_1",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Tobacco use",
    "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or  groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.",
    "measureId": "IA_BMH_2",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Depression screening",
    "description": "Depression screening and follow-up plan:  Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.",
    "measureId": "IA_BMH_4",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "MDD prevention and treatment interventions",
    "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.",
    "measureId": "IA_BMH_5",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Implementation of co-location PCP and MH services",
    "description": "Integration facilitation and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings.",
    "measureId": "IA_BMH_6",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Implementation of Integrated Patient Centered Behavioral Health Model",
    "description": "Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses.  The services could include one or more of the following: - Use evidence-based treatment protocols and treatment to goal where appropriate;- Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;- Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;- Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;- Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;- Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or- Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.",
    "measureId": "IA_BMH_7",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Electronic Health Record Enhancements for BH data capture",
    "description": "Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).",
    "measureId": "IA_BMH_8",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients",
    "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example:  NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.",
    "measureId": "IA_BMH_9",
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "weight": "high",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Completion of Collaborative Care Management Training Program",
    "description": "To receive credit for this activity, MIPS eligible clinicians must complete a collaborative care management training program, such as the American Psychiatric Association (APA) Collaborative Care Model training program available to the public, in order to implement a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice.",
    "measureId": "IA_BMH_10",
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "weight": "medium",
    "subcategoryId": "behavioralAndMentalHealth"
  },
  {
    "category": "ia",
    "title": "Electronic submission of Patient Centered Medical Home accreditation",
    "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.",
    "measureId": "IA_PCMH",
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "weight": null,
    "subcategoryId": null
  },
  {
    "category": "pi",
    "measureId": "PI_PPHI_1",
    "title": "Security Risk Analysis",
    "description": "Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "protectPatientHealthInformation",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Security%20Risk%20Analysis.pdf"
    },
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_ONCDIR_1",
    "title": "ONC Direct Review Attestation",
    "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "attestation",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_INFBLO_1",
    "title": "Prevention of Information Blocking Attestation",
    "description": "I attest to CMS that I - (A) did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (B) Implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: (1) Connected in accordance with applicable law; (2) Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170;  (3) Implemented in a manner that allowed for timely access by patients to their electronic health information; and (4) Implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors. (C) Responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor's affiliation or technology vendor.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "attestation",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_ONCACB_1",
    "title": "ONC-ACB Surveillance Attestation",
    "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "attestation",
    "isBonus": false,
    "reportingCategory": null,
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_EP_1",
    "title": "e-Prescribing",
    "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.",
    "isRequired": true,
    "metricType": "proportion",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "electronicPrescribing",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20ePrescribing.pdf"
    },
    "measureSets": [],
    "exclusion": [
      "PI_LVPP_1"
    ]
  },
  {
    "category": "pi",
    "measureId": "PI_LVPP_1",
    "title": "e-Prescribing Exclusion",
    "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "electronicPrescribing",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_EP_2",
    "title": "Query of the Prescription Drug Monitoring Program (PDMP)",
    "description": "For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a Prescription Drug Monitoring Program (PDMP) for prescription drug history, except where prohibited and in accordance with applicable law.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "electronicPrescribing",
    "isBonus": true,
    "reportingCategory": "bonus",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Query%20of%20PDMP.pdf"
    },
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_HIE_1",
    "title": "Support Electronic Referral Loops By Sending Health Information",
    "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider - (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.",
    "isRequired": true,
    "metricType": "proportion",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "healthInformationExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [
      "PI_HIE_5"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Support%20Electronic%20Referral%20Loops%20by%20Sending%20Health%20Info.pdf"
    },
    "measureSets": [],
    "exclusion": [
      "PI_LVOTC_1"
    ]
  },
  {
    "category": "pi",
    "measureId": "PI_LVOTC_1",
    "title": "Support Electronic Referral Loops By Sending Health Information Exclusion",
    "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "healthInformationExchange",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_HIE_4",
    "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information",
    "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.",
    "isRequired": true,
    "metricType": "proportion",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "healthInformationExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [
      "PI_HIE_5"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Support%20Electronic%20Referral%20Loops%20by%20Receiving%20Reconciling%20Health%20Information.pdf"
    },
    "measureSets": [],
    "exclusion": [
      "PI_LVITC_2"
    ]
  },
  {
    "category": "pi",
    "measureId": "PI_LVITC_2",
    "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion",
    "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "healthInformationExchange",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_HIE_5",
    "title": "Health Information Exchange(HIE) Bi-Directional Exchange",
    "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2021,
    "lastPerformanceYear": null,
    "objective": "healthInformationExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [
      "PI_HIE_1",
      "PI_HIE_4"
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    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Health%20Information%20Exchange%20(HIE)%20Bi-Directional%20Exchange.pdf"
    },
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PEA_1",
    "title": "Provide Patients Electronic Access to Their Health Information",
    "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).",
    "isRequired": true,
    "metricType": "proportion",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "providerToPatientExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Provide%20Patients%20Electronic%20Access%20to%20Their%20Health%20Information.pdf"
    },
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_2",
    "title": "Syndromic Surveillance Reporting",
    "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Syndromic%20Surveillance%20Reporting.pdf"
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    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_2_EX_1",
      "PI_PHCDRR_2_EX_2",
      "PI_PHCDRR_2_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_2_MULTI",
    "title": "Syndromic Surveillance Reporting for Multiple Registry Engagement",
    "description": "Report as true if,  active engagement with more than one Syndromic Surveillance registry in accordance with PI_PHCDRR_2.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_2_EX_1",
      "PI_PHCDRR_2_EX_2",
      "PI_PHCDRR_2_EX_3"
    ]
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_2_EX_1",
    "title": "Syndromic Surveillance Reporting Exclusion",
    "description": "Any MIPS eligible clinician who is not in a category of health care providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_2_EX_2",
      "PI_PHCDRR_2_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_2_EX_2",
    "title": "Syndromic Surveillance Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required to meet the CEHRT definition at the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_2_EX_1",
      "PI_PHCDRR_2_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_2_EX_3",
    "title": "Syndromic Surveillance Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from MIPS eligible clinicians as of 6 months prior to the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_2_EX_1",
      "PI_PHCDRR_2_EX_2"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_1",
    "title": "Immunization Registry Reporting",
    "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Immunization%20Registry%20Reporting.pdf"
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    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_1_EX_1",
      "PI_PHCDRR_1_EX_2",
      "PI_PHCDRR_1_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_1_MULTI",
    "title": "Immunization Registry Reporting for Multiple Registry Engagement",
    "description": "Report as true if active engagement with more than one immunization registry in accordance with PI_PHCDRR_1.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_1_EX_1",
      "PI_PHCDRR_1_EX_2",
      "PI_PHCDRR_1_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_1_EX_1",
    "title": "Immunization Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
    "isBonus": false,
    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_1_EX_2",
      "PI_PHCDRR_1_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_1_EX_2",
    "title": "Immunization Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_1_EX_1",
      "PI_PHCDRR_1_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_1_EX_3",
    "title": "Immunization Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_1_EX_1",
      "PI_PHCDRR_1_EX_2"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_3",
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    "description": "The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Electronic%20Case%20Reporting.pdf"
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    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_3_EX_1",
      "PI_PHCDRR_3_EX_2",
      "PI_PHCDRR_3_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_3_MULTI",
    "title": "Electronic Case Reporting for Multiple Registry Engagement",
    "description": "Report as true if,  active engagement with more than one Electronic Case Reporting registry in accordance with PI_PHCDRR_3.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_3_EX_1",
      "PI_PHCDRR_3_EX_2",
      "PI_PHCDRR_3_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_3_EX_1",
    "title": "Electronic Case Reporting Exclusion",
    "description": "Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_3_EX_2",
      "PI_PHCDRR_3_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_3_EX_2",
    "title": "Electronic Case Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_3_EX_1",
      "PI_PHCDRR_3_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_3_EX_3",
    "title": "Electronic Case Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_3_EX_1",
      "PI_PHCDRR_3_EX_2"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_4",
    "title": "Public Health Registry Reporting",
    "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
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    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Public%20Health%20Registry%20Reporting.pdf"
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    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_4_EX_1",
      "PI_PHCDRR_4_EX_2",
      "PI_PHCDRR_4_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_4_MULTI",
    "title": "Public Health Registry Reporting for Multiple Registry Engagement",
    "description": "Report as true if,  active engagement with more than one Public Health Registry in accordance with PI_PHCDRR_4.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
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    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": null,
    "measureSets": [],
    "exclusion": [
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      "PI_PHCDRR_4_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_4_EX_1",
    "title": "Public Health Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician's jurisdiction during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_4_EX_2",
      "PI_PHCDRR_4_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_4_EX_2",
    "title": "Public Health Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_4_EX_1",
      "PI_PHCDRR_4_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_4_EX_3",
    "title": "Public Health Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction where no public health registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
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    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_4_EX_1",
      "PI_PHCDRR_4_EX_2"
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    "measureSpecification": null,
    "measureSets": [],
    "exclusion": null
  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_5",
    "title": "Clinical Data Registry Reporting",
    "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.",
    "isRequired": true,
    "metricType": "boolean",
    "firstPerformanceYear": 2017,
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    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "required",
    "substitutes": [],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/pi_specifications/Measure%20Specifications/2021%20MIPS%20PI%20Clinical%20Data%20Registry%20Reporting.pdf"
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    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_5_EX_1",
      "PI_PHCDRR_5_EX_2",
      "PI_PHCDRR_5_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_5_MULTI",
    "title": "Clinical Data Registry Reporting for Multiple Registry Engagement",
    "description": "Report as true if, active engagement with more than one Clinical Data Registry in accordance with PI_PHCDRR_5.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2018,
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    "reportingCategory": "required",
    "substitutes": [],
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    "measureSets": [],
    "exclusion": [
      "PI_PHCDRR_5_EX_1",
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      "PI_PHCDRR_5_EX_3"
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_5_EX_1",
    "title": "Clinical Data Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_5_EX_2",
      "PI_PHCDRR_5_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_5_EX_2",
    "title": "Clinical Data Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no clinical data registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
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    "objective": "publicHealthAndClinicalDataExchange",
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_5_EX_1",
      "PI_PHCDRR_5_EX_3"
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    "measureSpecification": null,
    "measureSets": [],
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  },
  {
    "category": "pi",
    "measureId": "PI_PHCDRR_5_EX_3",
    "title": "Clinical Data Registry Reporting Exclusion",
    "description": "Any MIPS eligible clinician who operates in a jurisdiction where no clinical data registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.",
    "isRequired": false,
    "metricType": "boolean",
    "firstPerformanceYear": 2019,
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    "reportingCategory": "exclusion",
    "substitutes": [
      "PI_PHCDRR_5_EX_1",
      "PI_PHCDRR_5_EX_2"
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    "measureSpecification": null,
    "measureSets": [],
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  },
  {
    "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)",
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    "nqfEMeasureId": null,
    "nqfId": "0059",
    "measureId": "001",
    "description": "Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
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    "category": "quality",
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    "icdImpacted": [],
    "clinicalGuidelineChanged": [
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    "allowedPrograms": [
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    "submissionMethods": [
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    "measureSets": [
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      "preventiveMedicine",
      "nephrology",
      "endocrinology"
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    "measureSpecification": {
      "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms122v9",
      "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2021_Measure_DM-2_CMSWebInterface_v5.0.pdf",
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_001_MedicarePartBClaims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_001_MIPSCQM.pdf"
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    "eMeasureUuid": "2c928085-7198-38ee-0171-9d78a0d406b3",
    "strata": [
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        "description": "Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%",
        "eMeasureUuids": {
          "initialPopulationUuid": "C7396995-408E-4254-BF40-D2CD2A97E858",
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        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "4044F",
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      },
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            "code": "4044F"
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        ]
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            "code": "4044F",
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        ]
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    ]
  },
  {
    "title": "Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
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    "nqfEMeasureId": null,
    "nqfId": "0055",
    "measureId": "117",
    "description": "Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": false,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": true,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [
      "claims"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "claims",
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
      "familyMedicine",
      "internalMedicine",
      "ophthalmology",
      "endocrinology"
    ],
    "measureSpecification": {
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      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_117_MedicarePartBClaims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_117_MIPSCQM.pdf"
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      {
        "description": "Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following:\n•Diabetic with a diagnosis of retinopathy that overlaps the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period\n•Diabetic with no diagnosis of retinopathy overlapping the measurement period and a retinal or dilated eye exam by an eye care professional in the measurement period or the year prior to the measurement period",
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        "qualityCodes": [
          {
            "code": "G8418"
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        ]
      },
      {
        "optionGroup": "00",
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G8419"
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        ]
      },
      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "G8420"
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        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "G8421"
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        ]
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    "title": "Documentation of Current Medications in the Medical Record",
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    "nqfEMeasureId": "0419e",
    "nqfId": "0419",
    "measureId": "130",
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    "primarySteward": "Centers for Medicare & Medicaid Services",
    "metricType": "singlePerformanceRate",
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    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "isRiskAdjusted": false,
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      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "claims",
      "electronicHealthRecord",
      "registry"
    ],
    "measureSets": [
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      "cardiology",
      "gastroenterology",
      "dermatology",
      "familyMedicine",
      "internalMedicine",
      "obstetricsGynecology",
      "ophthalmology",
      "orthopedicSurgery",
      "otolaryngology",
      "physicalMedicine",
      "plasticSurgery",
      "preventiveMedicine",
      "neurology",
      "mentalBehavioralHealth",
      "vascularSurgery",
      "generalSurgery",
      "thoracicSurgery",
      "urology",
      "oncology",
      "hospitalists",
      "rheumatology",
      "nephrology",
      "infectiousDisease",
      "neurosurgical",
      "physicalTherapyOccupationalTherapy",
      "geriatrics",
      "urgentCare",
      "endocrinology",
      "nutritionDietician",
      "pulmonology",
      "clinicalSocialWork",
      "audiology",
      "speechLanguagePathology"
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    "measureSpecification": {
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      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_130_MedicarePartBClaims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_130_MIPSCQM.pdf"
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    "strata": [
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        "description": "Eligible professional or eligible clinician attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter",
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          "denominatorUuid": "07F5DB6C-B8EB-4614-AE90-84B76494A721",
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            "code": "59400"
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          {
            "code": "59510"
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          {
            "code": "59610"
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          {
            "code": "59618"
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          {
            "code": "90791"
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          {
            "code": "90792"
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          {
            "code": "90832"
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          {
            "code": "90834"
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          {
            "code": "90837"
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            "code": "90839"
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          {
            "code": "92002"
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          {
            "code": "92004"
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          {
            "code": "92012"
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          {
            "code": "92014"
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          {
            "code": "92507"
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          {
            "code": "92508"
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          {
            "code": "92526"
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          {
            "code": "92537"
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          {
            "code": "92538"
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            "code": "92540"
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            "code": "92541"
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          {
            "code": "92542"
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            "code": "92544"
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            "code": "92545"
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            "code": "92548"
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            "code": "92550"
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            "code": "92557"
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            "code": "92567"
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            "code": "92568"
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            "code": "92570"
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            "code": "92588"
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            "code": "92626"
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            "code": "96116"
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            "code": "96156"
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            "code": "96158"
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            "code": "97129"
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            "code": "97161"
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            "code": "97162"
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            "code": "97163"
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            "code": "97164"
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            "code": "97165"
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            "code": "97166"
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          {
            "code": "97167"
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          {
            "code": "97168"
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          {
            "code": "97802"
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          {
            "code": "97803"
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          {
            "code": "97804"
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          {
            "code": "98960"
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            "code": "98961"
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            "code": "98962"
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          {
            "code": "99202"
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            "code": "99203"
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            "code": "99204"
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          {
            "code": "99205"
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          {
            "code": "99212"
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          {
            "code": "99213"
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          {
            "code": "99214"
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          {
            "code": "99215"
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          {
            "code": "99221"
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          {
            "code": "99222"
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          {
            "code": "99223"
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          {
            "code": "99236"
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          {
            "code": "99281"
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            "code": "99282"
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          {
            "code": "99283"
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            "code": "99284"
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            "code": "99285"
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            "code": "99304"
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            "code": "99305"
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          {
            "code": "99306"
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          {
            "code": "99307"
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          {
            "code": "99308"
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          {
            "code": "99309"
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          {
            "code": "99310"
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          {
            "code": "99315"
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          {
            "code": "99316"
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          {
            "code": "99318"
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          {
            "code": "99324"
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          {
            "code": "99325"
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          {
            "code": "99326"
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          {
            "code": "99327"
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          {
            "code": "99328"
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          {
            "code": "99334"
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          {
            "code": "99335"
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          {
            "code": "99336"
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          {
            "code": "99337"
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          {
            "code": "99339"
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          {
            "code": "99340"
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          {
            "code": "99341"
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          {
            "code": "99342"
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          {
            "code": "99343"
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            "code": "99344"
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            "code": "99345"
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            "code": "99347"
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            "code": "99348"
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            "code": "99349"
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            "code": "99350"
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            "code": "99385"
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          {
            "code": "99386"
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          {
            "code": "99387"
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          {
            "code": "99395"
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            "code": "99396"
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          {
            "code": "99397"
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          {
            "code": "99495"
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          {
            "code": "99496"
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          {
            "code": "G0101"
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          {
            "code": "G0108"
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          {
            "code": "G0270"
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          {
            "code": "G0402"
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          {
            "code": "G0438"
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          {
            "code": "G0439"
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        "optionGroup": "00",
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            "code": "G8430"
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        "optionGroup": "00",
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        "qualityCodes": [
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            "code": "G8427"
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        "optionGroup": "00",
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            "code": "G8428"
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      "app1"
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      "physicalTherapyOccupationalTherapy",
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      "speechLanguagePathology"
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      "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2021_Measure_PREV12_CMSWebInterface_v5.0.pdf",
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_134_MedicarePartBClaims.pdf",
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        "minAge": 12,
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            "code": "59400"
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            "code": "59510"
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          {
            "code": "59610"
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          {
            "code": "59618"
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            "code": "90791"
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          {
            "code": "90792"
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          {
            "code": "90832"
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          {
            "code": "90834"
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          {
            "code": "90837"
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          {
            "code": "92625"
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            "code": "96105"
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            "code": "96110"
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          {
            "code": "96112"
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            "code": "96116"
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            "code": "96125"
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            "code": "96136"
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            "code": "96138"
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            "code": "96158"
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            "code": "97161"
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            "code": "97162"
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            "code": "97163"
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            "code": "97165"
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            "code": "97166"
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            "code": "97167"
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            "code": "99078"
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            "code": "99202"
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            "code": "99203"
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            "code": "99204"
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            "code": "99205"
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            "code": "99212"
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            "code": "99213"
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            "code": "99214"
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            "code": "99215"
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            "code": "99304"
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            "code": "99326"
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            "code": "99328"
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            "code": "99334"
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            "code": "99335"
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            "code": "99336"
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            "code": "99337"
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            "code": "99339"
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            "code": "99340"
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            "code": "99384"
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            "code": "99385"
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            "code": "99386"
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            "code": "99387"
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          {
            "code": "99394"
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            "code": "99395"
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            "code": "99396"
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            "code": "99397"
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          {
            "code": "99401"
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          {
            "code": "99402"
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          {
            "code": "99403"
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          {
            "code": "99483"
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          {
            "code": "99484"
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          {
            "code": "99492"
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          {
            "code": "99493"
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          {
            "code": "96156"
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          {
            "code": "G0101"
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            "code": "G0402"
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          {
            "code": "G0438"
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          {
            "code": "G0439"
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          {
            "code": "G0444"
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            "code": "F01.51"
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            "code": "F31.12"
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            "code": "F31.4"
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            "code": "F31.5"
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            "code": "F31.60"
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            "code": "F31.61"
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            "code": "F31.64"
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            "code": "F31.70"
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            "code": "F31.71"
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        "optionGroup": "00",
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            "code": "F31.72"
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        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F31.73"
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        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F31.74"
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      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F31.75"
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      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F31.76"
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      {
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        "qualityCodes": [
          {
            "code": "F31.77"
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        "qualityCodes": [
          {
            "code": "F31.78"
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        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F31.81"
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      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F31.89"
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      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "F31.9"
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      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "F32.0"
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        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "F32.1"
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      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "F32.2"
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      },
      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F32.3"
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      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
            "code": "F32.4"
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        ]
      },
      {
        "optionGroup": "00",
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        "qualityCodes": [
          {
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            "code": "36221"
          },
          {
            "code": "36222"
          },
          {
            "code": "36223"
          },
          {
            "code": "36224"
          },
          {
            "code": "37215"
          },
          {
            "code": "37216"
          },
          {
            "code": "37217"
          },
          {
            "code": "37218"
          },
          {
            "code": "70498"
          },
          {
            "code": "70547"
          },
          {
            "code": "70548"
          },
          {
            "code": "70549"
          },
          {
            "code": "93880"
          },
          {
            "code": "93882"
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        ]
      }
    ],
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      {
        "optionGroup": "00",
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            "code": "3100F"
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        ]
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      {
        "optionGroup": "00",
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          {
            "code": "3100F",
            "modifiers": [
              "8P"
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          }
        ]
      }
    ]
  },
  {
    "title": "HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0409",
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    "description": "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": false,
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    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
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    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
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    ],
    "measureSets": [
      "pediatrics",
      "infectiousDisease"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_205_MIPSCQM.pdf"
    }
  },
  {
    "title": "Functional Status Change for Patients with Knee Impairments",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "217",
    "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "patientReportedOutcome",
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "orthopedicSurgery",
      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_217_MIPSCQM.pdf"
    }
  },
  {
    "title": "Functional Status Change for Patients with Hip Impairments",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "218",
    "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "patientReportedOutcome",
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
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    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
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    ],
    "submissionMethods": [
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    ],
    "measureSets": [
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      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_218_MIPSCQM.pdf"
    }
  },
  {
    "title": "Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "219",
    "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "patientReportedOutcome",
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "isIcdImpacted": false,
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    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
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      "mips",
      "cpcPlus",
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    ],
    "submissionMethods": [
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    ],
    "measureSets": [
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      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_219_MIPSCQM.pdf"
    }
  },
  {
    "title": "Functional Status Change for Patients with Low Back Impairments",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "220",
    "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the FOTO Low Back FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
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    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
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    "measureSets": [
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      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
    ],
    "measureSpecification": {
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    }
  },
  {
    "title": "Functional Status Change for Patients with Shoulder Impairments",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "221",
    "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the FOTO Shoulder FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
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    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
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    ],
    "submissionMethods": [
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    "measureSets": [
      "orthopedicSurgery",
      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_221_MIPSCQM.pdf"
    }
  },
  {
    "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "222",
    "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with elbow, wrist, or hand impairments. The change in functional status (FS) is assessed using the FOTO Elbow/Wrist/Hand FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "patientReportedOutcome",
    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
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    "isRiskAdjusted": false,
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    ],
    "measureSets": [
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      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_222_MIPSCQM.pdf"
    }
  },
  {
    "title": "Radiology: Reminder System for Screening Mammograms",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0509",
    "measureId": "225",
    "description": "Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "structure",
    "primarySteward": "American College of Radiology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
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    "isRiskAdjusted": false,
    "icdImpacted": [],
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    ],
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "diagnosticRadiology"
    ],
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_measure_225_MedicarePartBClaims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_225_MIPSCQM.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "Z12.31"
        ],
        "minAge": 0,
        "optionGroup": "00",
        "procedureCodes": [
          {
            "code": "77067"
          }
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionGroup": "00",
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "7025F"
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        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "7025F",
            "modifiers": [
              "1P"
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          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "7025F",
            "modifiers": [
              "8P"
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          }
        ]
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    ]
  },
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    "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention",
    "eMeasureId": "CMS138v9",
    "nqfEMeasureId": "0028e",
    "nqfId": "0028",
    "measureId": "226",
    "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user. Three rates are reported: a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention  c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "multiPerformanceRate",
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    "isHighPriority": false,
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    "overallAlgorithm": "overallStratumOnly",
    "isIcdImpacted": false,
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    "icdImpacted": [],
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    ],
    "submissionMethods": [
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    "measureSets": [
      "allergyImmunology",
      "cardiology",
      "gastroenterology",
      "dermatology",
      "familyMedicine",
      "internalMedicine",
      "obstetricsGynecology",
      "ophthalmology",
      "orthopedicSurgery",
      "otolaryngology",
      "physicalMedicine",
      "plasticSurgery",
      "preventiveMedicine",
      "neurology",
      "mentalBehavioralHealth",
      "vascularSurgery",
      "generalSurgery",
      "thoracicSurgery",
      "urology",
      "oncology",
      "rheumatology",
      "neurosurgical",
      "podiatry",
      "physicalTherapyOccupationalTherapy",
      "urgentCare",
      "endocrinology",
      "pulmonology",
      "clinicalSocialWork",
      "audiology",
      "speechLanguagePathology"
    ],
    "measureSpecification": {
      "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms138v9",
      "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2021_Measure_PREV10_CMSWebInterface_v5.0.pdf",
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_226_MedicarePartBClaims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_226_MIPSCQM.pdf"
    },
    "strata": [
      {
        "name": "screenedForUse",
        "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months",
        "eMeasureUuids": {
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          "denominatorUuid": "69248984-A61F-4E87-B75B-73EA2EFCE11F",
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      },
      {
        "name": "overall",
        "description": "Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention",
        "eMeasureUuids": {
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        "name": "tobacco",
        "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user",
        "eMeasureUuids": {
          "initialPopulationUuid": "B986CD1C-A155-48EC-BE5A-3F5508491265",
          "denominatorUuid": "87010EBD-E324-477C-BDF1-D8690B282D6A",
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    "eligibilityOptions": [
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            "code": "99386"
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            "code": "99387"
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            "code": "99395"
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          {
            "code": "99396"
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            "code": "99397"
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            "code": "99401"
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            "code": "99402"
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            "code": "99403"
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          {
            "code": "99404"
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            "code": "99411"
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          {
            "code": "99412"
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          {
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          {
            "code": "G0438"
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          {
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        ]
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        "procedureCodes": [
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          {
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          {
            "code": "90832"
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            "code": "90834"
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          {
            "code": "90837"
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          {
            "code": "90845"
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          {
            "code": "92004"
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          {
            "code": "92012"
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          {
            "code": "92014"
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          {
            "code": "92521"
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          {
            "code": "92522"
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          {
            "code": "92523"
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          {
            "code": "92524"
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          {
            "code": "92540"
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          {
            "code": "92557"
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          {
            "code": "92625"
          },
          {
            "code": "96156"
          },
          {
            "code": "96158"
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          {
            "code": "97161"
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          {
            "code": "97162"
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          {
            "code": "97163"
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          {
            "code": "97165"
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          {
            "code": "97166"
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          {
            "code": "97167"
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          {
            "code": "97168"
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          {
            "code": "99202"
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          {
            "code": "99203"
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    "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows:                                                                                                                                                                                                                                                                                         • Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)• How well Providers Communicate; (Not endorsed by NQF)• Patient’s Rating of Provider; (NQF endorsed # 0005)• Access to Specialists; (Not endorsed by NQF)• Health Promotion and Education; (Not endorsed by NQF)• Shared Decision-Making; (Not endorsed by NQF) • Health Status and Functional Status; (Not endorsed by NQF)• Courteous and Helpful Office Staff; (NQF endorsed # 0005)• Care Coordination; (Not endorsed by NQF)• Stewardship of Patient Resources. (Not endorsed by NQF)",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "patientEngagementExperience",
    "primarySteward": "Agency for Healthcare Research & Quality",
    "metricType": "cahps",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "familyMedicine",
      "internalMedicine"
    ],
    "measureSpecification": {}
  },
  {
    "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "322",
    "description": "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 submission period.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "primarySteward": "American College of Cardiology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "cardiology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_322_MIPSCQM.pdf"
    }
  },
  {
    "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "323",
    "description": "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.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "primarySteward": "American College of Cardiology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "cardiology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_323_MIPSCQM.pdf"
    }
  },
  {
    "title": "Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "324",
    "description": "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.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "primarySteward": "American College of Cardiology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "cardiology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_324_MIPSCQM.pdf"
    }
  },
  {
    "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1525",
    "measureId": "326",
    "description": "Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "American College of Cardiology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": false,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "claims",
      "registry"
    ],
    "measureSets": [
      "cardiology",
      "familyMedicine",
      "internalMedicine",
      "skilledNursingFacility"
    ],
    "measureSpecification": {
      "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_measure_326_MedicarePartBClaims.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_326_mipscqm.pdf"
    },
    "eligibilityOptions": [
      {
        "diagnosisCodes": [
          "I48.0",
          "I48.11",
          "I48.19",
          "I48.20",
          "I48.21",
          "I48.3",
          "I48.4",
          "I48.91",
          "I48.92"
        ],
        "minAge": 18,
        "optionGroup": "00",
        "procedureCodes": [
          {
            "code": "99202"
          },
          {
            "code": "99203"
          },
          {
            "code": "99204"
          },
          {
            "code": "99205"
          },
          {
            "code": "99212"
          },
          {
            "code": "99213"
          },
          {
            "code": "99214"
          },
          {
            "code": "99215"
          },
          {
            "code": "99241"
          },
          {
            "code": "99242"
          },
          {
            "code": "99243"
          },
          {
            "code": "99244"
          },
          {
            "code": "99245"
          },
          {
            "code": "99304"
          },
          {
            "code": "99305"
          },
          {
            "code": "99306"
          },
          {
            "code": "99307"
          },
          {
            "code": "99308"
          },
          {
            "code": "99309"
          },
          {
            "code": "99310"
          },
          {
            "code": "99324"
          },
          {
            "code": "99325"
          },
          {
            "code": "99326"
          },
          {
            "code": "99327"
          },
          {
            "code": "99328"
          },
          {
            "code": "99334"
          },
          {
            "code": "99335"
          },
          {
            "code": "99336"
          },
          {
            "code": "99337"
          },
          {
            "code": "99341"
          },
          {
            "code": "99342"
          },
          {
            "code": "99343"
          },
          {
            "code": "99344"
          },
          {
            "code": "99345"
          },
          {
            "code": "99347"
          },
          {
            "code": "99348"
          },
          {
            "code": "99349"
          },
          {
            "code": "99350"
          }
        ]
      }
    ],
    "performanceOptions": [
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G8968"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G8969"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationException",
        "qualityCodes": [
          {
            "code": "G9927"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9929"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9930"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "eligiblePopulationExclusion",
        "qualityCodes": [
          {
            "code": "G9931"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "performanceMet",
        "qualityCodes": [
          {
            "code": "G8967"
          }
        ]
      },
      {
        "optionGroup": "00",
        "optionType": "performanceNotMet",
        "qualityCodes": [
          {
            "code": "G9928"
          }
        ]
      }
    ]
  },
  {
    "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "331",
    "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "emergencyMedicine",
      "familyMedicine",
      "internalMedicine",
      "otolaryngology",
      "urgentCare"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_331_MIPSCQM.pdf"
    }
  },
  {
    "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "332",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "emergencyMedicine",
      "familyMedicine",
      "internalMedicine",
      "otolaryngology",
      "urgentCare"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_332_MIPSCQM.pdf"
    }
  },
  {
    "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "335",
    "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries by cesarean section (C-section), or early inductions of labor, without medical indication.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "obstetricsGynecology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_335_MIPSCQM.pdf"
    }
  },
  {
    "title": "Maternity Care: Postpartum Follow-up and Care Coordination",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "336",
    "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 8 weeks of giving birth and received the following at the postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "obstetricsGynecology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_336_MIPSCQM.pdf"
    }
  },
  {
    "title": "Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "337",
    "description": "Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through 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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "American Academy of Dermatology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": false,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "dermatology",
      "familyMedicine",
      "internalMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_337_MIPSCQM.pdf"
    }
  },
  {
    "title": "HIV Viral Load Suppression",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "2082",
    "measureId": "338",
    "description": "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "primarySteward": "Health Resources and Services Administration",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "familyMedicine",
      "internalMedicine",
      "infectiousDisease"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_338_MIPSCQM.pdf"
    }
  },
  {
    "title": "HIV Medical Visit Frequency",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "2079",
    "measureId": "340",
    "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "primarySteward": "Health Resources and Services Administration",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "allergyImmunology",
      "infectiousDisease"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_340_MIPSCQM.pdf"
    }
  },
  {
    "title": "Pain Brought Under Control Within 48 Hours",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0209",
    "measureId": "342",
    "description": "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.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "outcome",
    "primarySteward": "National Hospice and Palliative Care Organization",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "familyMedicine",
      "internalMedicine"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_342_MIPSCQM.pdf"
    }
  },
  {
    "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "344",
    "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "primarySteward": "Society for Vascular Surgery",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "submissionMethods": [
      "registry"
    ],
    "measureSets": [
      "cardiology",
      "vascularSurgery",
      "neurosurgical"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_344_MIPSCQM.pdf"
    }
  },
  {
    "title": "Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "350",
    "description": "Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "American Association of Hip and Knee Surgeons",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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    "title": "Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation",
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    "description": "Percentage of patients regardless of age 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).",
    "nationalQualityStrategyDomain": "Patient Safety",
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    "primarySteward": "American Association of Hip and Knee Surgeons",
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    }
  },
  {
    "title": "Anastomotic Leak Intervention",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "354",
    "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.",
    "nationalQualityStrategyDomain": "Patient Safety",
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      "pcf"
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    }
  },
  {
    "title": "Unplanned Reoperation within the 30 Day Postoperative Period",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "355",
    "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.",
    "nationalQualityStrategyDomain": "Patient Safety",
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    "primarySteward": "American College of Surgeons",
    "metricType": "singlePerformanceRate",
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      "generalSurgery"
    ],
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    }
  },
  {
    "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "356",
    "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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    "primarySteward": "American College of Surgeons",
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    ],
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    }
  },
  {
    "title": "Surgical Site Infection (SSI)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "measureId": "357",
    "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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    "primarySteward": "American College of Surgeons",
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      "vascularSurgery",
      "generalSurgery"
    ],
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    }
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    "title": "Patient-Centered Surgical Risk Assessment and Communication",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "358",
    "description": "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.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "primarySteward": "American College of Surgeons",
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      "vascularSurgery",
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      "thoracicSurgery",
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    ],
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    }
  },
  {
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "360",
    "description": "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.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "primarySteward": "American College of Radiology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
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    "isHighPriority": true,
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    }
  },
  {
    "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "364",
    "description": "Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
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    }
  },
  {
    "title": "Follow-Up Care for Children Prescribed ADHD Medication (ADD)",
    "eMeasureId": "CMS136v10",
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "366",
    "description": "Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.  a) Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.b) Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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    "isHighPriority": false,
    "isInverse": false,
    "overallAlgorithm": "simpleAverage",
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    "submissionMethods": [
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      "mentalBehavioralHealth"
    ],
    "measureSpecification": {
      "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms136v10"
    },
    "strata": [
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          "denominatorExclusionUuid": "EF583993-6453-4B51-97B3-84FAF366B3F6"
        },
        "name": "visitWithin30Days"
      },
      {
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  {
    "title": "Depression Remission at Twelve Months",
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    "nqfEMeasureId": "0710e",
    "nqfId": "0710",
    "measureId": "370",
    "description": "The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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    "primarySteward": "Minnesota Community Measurement",
    "metricType": "multiPerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "overallAlgorithm": "weightedAverage",
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    "submissionMethods": [
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    "measureSets": [
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      "internalMedicine",
      "pediatrics",
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      "geriatrics",
      "clinicalSocialWork"
    ],
    "measureSpecification": {
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_370_MIPSCQM.pdf"
    },
    "strata": [
      {
        "description": "Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an\ninitial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve\nmonths as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5.",
        "eMeasureUuids": {
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      }
    ],
    "eMeasureUuid": "2c928085-7198-38ee-0171-9e951ae1097e"
  },
  {
    "title": "Closing the Referral Loop: Receipt of Specialist Report",
    "eMeasureId": "CMS50v9",
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "374",
    "description": "Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "metricType": "singlePerformanceRate",
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    "isHighPriority": true,
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    ],
    "measureSets": [
      "allergyImmunology",
      "cardiology",
      "gastroenterology",
      "dermatology",
      "familyMedicine",
      "internalMedicine",
      "obstetricsGynecology",
      "ophthalmology",
      "orthopedicSurgery",
      "otolaryngology",
      "physicalMedicine",
      "preventiveMedicine",
      "neurology",
      "mentalBehavioralHealth",
      "interventionalRadiology",
      "vascularSurgery",
      "generalSurgery",
      "thoracicSurgery",
      "urology",
      "oncology",
      "rheumatology",
      "endocrinology",
      "pulmonology"
    ],
    "measureSpecification": {
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    },
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    "strata": [
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    "title": "Functional Status Assessment for Total Knee Replacement",
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    "nqfId": null,
    "measureId": "375",
    "description": "Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
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    "isHighPriority": true,
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    "measureSets": [
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    "strata": [
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  {
    "title": "Functional Status Assessment for Total Hip Replacement",
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    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "376",
    "description": "Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "primarySteward": "Centers for Medicare & Medicaid Services",
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    "isHighPriority": true,
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    "submissionMethods": [
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    "title": "Functional Status Assessments for Congestive Heart Failure",
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    "title": "Children Who Have Dental Decay or Cavities",
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  {
    "title": "Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists",
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    "description": "Percentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement period.",
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  {
    "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment",
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  {
    "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia",
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    "nqfId": "1879",
    "measureId": "383",
    "description": "Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.",
    "nationalQualityStrategyDomain": "Patient Safety",
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  },
  {
    "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "384",
    "description": "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
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    }
  },
  {
    "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery",
    "eMeasureId": null,
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    "description": "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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  {
    "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences",
    "eMeasureId": null,
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    "nqfId": null,
    "measureId": "386",
    "description": "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.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "process",
    "primarySteward": "American Academy of Neurology",
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  },
  {
    "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "387",
    "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "American Gastroenterological Association",
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    }
  },
  {
    "title": "Cataract Surgery: Difference Between Planned and Final Refraction",
    "eMeasureId": null,
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    "nqfId": null,
    "measureId": "389",
    "description": "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.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "primarySteward": "American Academy of Ophthalmology",
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  {
    "title": "Follow-Up After Hospitalization for Mental Illness (FUH)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0576",
    "measureId": "391",
    "description": "The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: • The percentage of discharges for which the patient received follow-up within 30 days after discharge. • The percentage of discharges for which the patient received follow-up within 7 days after discharge.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "multiPerformanceRate",
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    "overallAlgorithm": "overallStratumOnly",
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    "strata": [
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        "description": "The percentage of discharges for which the patient received follow-up within 30 days after discharge"
      },
      {
        "name": "overall",
        "description": "The percentage of discharges for which the patient received follow-up within 7 days after discharge"
      }
    ]
  },
  {
    "title": "Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation",
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    "measureId": "392",
    "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:• Submission Age Criteria 1: Females 18-64 years of age• Submission Age Criteria 2: Males 18-64 years of age• Submission Age Criteria 3: Females 65 years of age and older• Submission Age Criteria 4: Males 65 years of age and older",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "primarySteward": "American College of Cardiology Foundation",
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      {
        "name": "18-64M",
        "description": "Males 18-64 years of age"
      },
      {
        "name": "65+F",
        "description": "Females 65 years of age and older"
      },
      {
        "name": "65+M",
        "description": "Males 65 years of age and older"
      },
      {
        "name": "overall",
        "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days"
      }
    ]
  },
  {
    "title": "Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "393",
    "description": "Infection rate following CIED device implantation, replacement, or revision.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "primarySteward": "American College of Cardiology Foundation",
    "metricType": "singlePerformanceRate",
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    "isHighPriority": true,
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  },
  {
    "title": "Immunizations for Adolescents",
    "eMeasureId": null,
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    "nqfId": null,
    "measureId": "394",
    "description": "The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "multiPerformanceRate",
    "firstPerformanceYear": 2017,
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    "submissionMethods": [
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    "measureSets": [
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    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_394_MIPSCQM.pdf"
    },
    "strata": [
      {
        "name": "meningococcal",
        "description": "Patients who had one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays"
      },
      {
        "name": "Tdap",
        "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient's 10th and 13th birthdays"
      },
      {
        "name": "HPV",
        "description": "Patients who have completed the HPV vaccine with defferent dates of service on or between the patient's 9th and 13th birthdays"
      },
      {
        "name": "overall",
        "description": "All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes"
      }
    ]
  },
  {
    "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "395",
    "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "College of American Pathologists",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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        "name": "lowRisk5-17",
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    "title": "One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk",
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          {
            "code": "74183"
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          {
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          {
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          {
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            "code": "70488"
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            "code": "70490"
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          {
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          {
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          {
            "code": "70498"
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          {
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          {
            "code": "70542"
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          {
            "code": "70543"
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          {
            "code": "70547"
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          {
            "code": "70548"
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            "code": "72156"
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    "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:• Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR• Adults aged ≥ 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "metricType": "singlePerformanceRate",
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      "pcf"
    ],
    "submissionMethods": [
      "electronicHealthRecord",
      "cmsWebInterface",
      "registry"
    ],
    "measureSets": [
      "cardiology",
      "familyMedicine",
      "internalMedicine",
      "preventiveMedicine",
      "endocrinology"
    ],
    "measureSpecification": {
      "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms347v4",
      "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2021_Measure_PREV13_CMSWebInterface_v5.0.pdf",
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_438_MIPSCQM.pdf"
    },
    "eMeasureUuid": "2c928085-7198-38ee-0171-989a534a0146",
    "strata": [
      {
        "name": "clinicalASCVD",
        "description": "Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD)",
        "eMeasureUuids": {
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          "denominatorUuid": "C0FE1159-81F5-449B-83EB-3395FC3A3210",
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      },
      {
        "name": ">21Familial",
        "description": "Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia",
        "eMeasureUuids": {
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          "denominatorUuid": "DA3E9773-E6F9-415E-B6DF-9DFDAB829D91",
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          "denominatorExceptionUuid": "84CD03D9-6BAA-4C56-9205-2F5A22CBDEE6"
        }
      },
      {
        "name": "between40And75",
        "description": "Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL",
        "eMeasureUuids": {
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  },
  {
    "title": "Age Appropriate Screening Colonoscopy",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "439",
    "description": "The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "primarySteward": "American Gastroenterological Association",
    "metricType": "singlePerformanceRate",
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    "measureSets": [
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    },
    "benchmarks": {
      "registry": "removed"
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  },
  {
    "title": "Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "440",
    "description": "Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "American Academy of Dermatology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
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    "submissionMethods": [
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    "measureSets": [
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      "pathology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_440_MIPSCQM.pdf"
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  },
  {
    "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "441",
    "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:•  Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND• Most recent tobacco status is Tobacco Free -- AND• Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND• Statin Use Unless Contraindicated",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "primarySteward": "Wisconsin Collaborative for Healthcare Quality",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "submissionMethods": [
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    "measureSets": [
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      "familyMedicine",
      "internalMedicine",
      "vascularSurgery"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_441_MIPSCQM.pdf"
    }
  },
  {
    "title": "Non-Recommended Cervical Cancer Screening in Adolescent Females",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "443",
    "description": "The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "icdImpacted": [],
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    "allowedPrograms": [
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    ],
    "submissionMethods": [
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    ],
    "measureSets": [
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      "internalMedicine",
      "obstetricsGynecology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_443_MIPSCQM.pdf"
    }
  },
  {
    "title": "Medication Management for People with Asthma",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "444",
    "description": "The percentage of patients 5-64 years of age during the performance period who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "primarySteward": "National Committee for Quality Assurance",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "isRiskAdjusted": false,
    "icdImpacted": [],
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    "allowedPrograms": [
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    ],
    "submissionMethods": [
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    ],
    "measureSets": [
      "allergyImmunology",
      "familyMedicine",
      "internalMedicine",
      "pediatrics",
      "pulmonology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_444_MIPSCQM.pdf"
    }
  },
  {
    "title": "Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0119",
    "measureId": "445",
    "description": "Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "primarySteward": "Society of Thoracic Surgeons",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "icdImpacted": [],
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    "allowedPrograms": [
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    ],
    "submissionMethods": [
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    ],
    "measureSets": [
      "thoracicSurgery"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_445_MIPSCQM.pdf"
    }
  },
  {
    "title": "Appropriate Workup Prior to Endometrial Ablation",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "448",
    "description": "Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "primarySteward": "Centers for Medicare & Medicaid Services",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    ],
    "submissionMethods": [
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    "measureSets": [
      "obstetricsGynecology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_448_MIPSCQM.pdf"
    }
  },
  {
    "title": "Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1858",
    "measureId": "450",
    "description": "Percentage of female patients aged 18 to 70 with stage I (T1c) - III HER2 positive breast cancer for whom appropriate treatment is initiated.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "American Society of Clinical Oncology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "submissionMethods": [
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    "measureSets": [
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    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_450_MIPSCQM.pdf"
    },
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "title": "RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1859",
    "measureId": "451",
    "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "American Society of Clinical Oncology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": false,
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    "icdImpacted": [],
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
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    ],
    "submissionMethods": [
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    ],
    "measureSets": [
      "oncology"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_451_MIPSCQM.pdf"
    }
  },
  {
    "title": "Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "1860",
    "measureId": "452",
    "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "primarySteward": "American Society of Clinical Oncology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
    "isIcdImpacted": false,
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    "measureSets": [
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    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_452_MIPSCQM.pdf"
    }
  },
  {
    "title": "Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0210",
    "measureId": "453",
    "description": "Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "primarySteward": "American Society of Clinical Oncology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
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    "icdImpacted": [],
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    "submissionMethods": [
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    "measureSets": [
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    "measureSpecification": {
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    }
  },
  {
    "title": "Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0213",
    "measureId": "455",
    "description": "Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "primarySteward": "American Society of Clinical Oncology",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "submissionMethods": [
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    "measureSets": [
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      "geriatrics"
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    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_455_MIPSCQM.pdf"
    }
  },
  {
    "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0216",
    "measureId": "457",
    "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "primarySteward": "American Society of Clinical Oncology",
    "metricType": "singlePerformanceRate",
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    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_457_MIPSCQM.pdf"
    }
  },
  {
    "title": "Back Pain After Lumbar Discectomy/Laminectomy",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "459",
    "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "primarySteward": "Minnesota Community Measurement",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": false,
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    "allowedPrograms": [
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      "cpcPlus",
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    ],
    "submissionMethods": [
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    "measureSets": [
      "orthopedicSurgery",
      "neurosurgical"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_459_MIPSCQM.pdf"
    }
  },
  {
    "title": "Back Pain After Lumbar Fusion",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "460",
    "description": "For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively.* hereafter referred to as VAS Pain",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "primarySteward": "Minnesota Community Measurement",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2018,
    "lastPerformanceYear": null,
    "isHighPriority": true,
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    "submissionMethods": [
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    "measureSets": [
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      "neurosurgical"
    ],
    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_460_MIPSCQM.pdf"
    }
  },
  {
    "title": "Leg Pain After Lumbar Discectomy/Laminectomy",
    "eMeasureId": null,
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    "nqfId": null,
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    "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS Pain scale at three months (6 to 20 weeks) postoperatively.",
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    "primarySteward": "Minnesota Community Measurement",
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      "mips",
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    "submissionMethods": [
      "registry"
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    "measureSets": [
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      "neurosurgical"
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_461_MIPSCQM.pdf"
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  },
  {
    "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy",
    "eMeasureId": "CMS645v4",
    "nqfEMeasureId": null,
    "nqfId": null,
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    "description": "Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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    "primarySteward": "Oregon Urology Institute",
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      "mips",
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    "submissionMethods": [
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      "urology",
      "oncology",
      "endocrinology"
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    "measureSpecification": {
      "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms645v4"
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    "eMeasureUuid": "2c928085-7198-38ee-0171-991e164e0307",
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      {
        "description": "Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment",
        "eMeasureUuids": {
          "initialPopulationUuid": "52F12771-64AC-4236-88D1-5780F5709BE8",
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  {
    "title": "Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)",
    "eMeasureId": null,
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    "nqfId": null,
    "measureId": "463",
    "description": "Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.",
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    "primarySteward": "American Society of Anesthesiologists",
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      "mips",
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_463_MIPSCQM.pdf"
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  },
  {
    "title": "Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0657",
    "measureId": "464",
    "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.",
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    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation",
    "metricType": "singlePerformanceRate",
    "firstPerformanceYear": 2018,
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      "mips",
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    "submissionMethods": [
      "registry"
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    "measureSets": [
      "familyMedicine",
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    "measureSpecification": {
      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_464_MIPSCQM.pdf"
    }
  },
  {
    "title": "Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "465",
    "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.",
    "nationalQualityStrategyDomain": "Patient Safety",
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    "primarySteward": "Society of Interventional Radiology",
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    "measureSets": [
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_465_MIPSCQM.pdf"
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  },
  {
    "title": "Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "468",
    "description": "Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.",
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    "measureType": "process",
    "primarySteward": "University of Southern California",
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  },
  {
    "title": "Functional Status After Lumbar Fusion",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "469",
    "description": "For patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a)* at one year (9 to 15 months) postoperatively.* hereafter referred to as ODI",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
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      "neurosurgical"
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_469_MIPSCQM.pdf"
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  },
  {
    "title": "Functional Status After Primary Total Knee Replacement",
    "eMeasureId": null,
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    "nqfId": null,
    "measureId": "470",
    "description": "For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.",
    "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes",
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      "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_470_MIPSCQM.pdf"
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  },
  {
    "title": "Functional Status After Lumbar Discectomy/Laminectomy",
    "eMeasureId": null,
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    "nqfId": null,
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    "description": "For patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively.* hereafter referred to as ODI",
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  },
  {
    "title": "Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture",
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    "nqfEMeasureId": "3475e",
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    "description": "Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.",
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
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    "measureSpecification": {
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        "description": "Female patients who received an order for at least one DXA scan in the measurement period",
        "eMeasureUuids": {
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          "denominatorUuid": "5676A192-5602-44B5-886A-23A045008F0F",
          "numeratorUuid": "906BE36C-F868-4A84-9C5F-75D2A259801C",
          "denominatorExclusionUuid": "634D7208-01BE-40B0-AAD9-27DC6ED13395"
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  },
  {
    "title": "Leg Pain After Lumbar Fusion",
    "eMeasureId": null,
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    "measureId": "473",
    "description": "For patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively. * hereafter referred to as VAS Pain.",
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    "measureType": "patientReportedOutcome",
    "primarySteward": "Minnesota Community Measurement",
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  },
  {
    "title": "HIV Screening",
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    "description": "Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.",
    "nationalQualityStrategyDomain": "Community/Population Health",
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    "measureSpecification": {
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        "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday",
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          "denominatorUuid": "E61633B7-37B5-430A-9890-CF4F9E659096",
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    "title": "Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia",
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    "description": "Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.",
    "nationalQualityStrategyDomain": "Person and Caregiver-centered Experience and Outcomes",
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    "measureSpecification": {
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        "description": "Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period",
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  {
    "title": "Multimodal Pain Management",
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    "description": "Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.",
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  {
    "title": "Functional Status Change for Patients with Neck Impairments",
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    "nqfId": null,
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    "description": "This is a patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paper-pencil).",
    "nationalQualityStrategyDomain": "Person and Caregiver-centered Experience and Outcomes",
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    "primarySteward": "Focus on Therapeutic Outcomes, Inc.",
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      "physicalTherapyOccupationalTherapy",
      "chiropracticMedicine"
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    "measureSpecification": {
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    "benchmarks": {
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    "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups",
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    "measureId": "479",
    "description": "This measure is a re-specified version of the measure, “Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition” (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group’s readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.",
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "primarySteward": "Centers for Medicare & Medicaid Services (CMS)",
    "metricType": "costScore",
    "firstPerformanceYear": 2021,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSets": [],
    "measureSpecification": {}
  },
  {
    "title": "Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "3493",
    "measureId": "480",
    "description": "This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.",
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "primarySteward": "Centers for Medicare & Medicaid Services (CMS)",
    "metricType": "costScore",
    "firstPerformanceYear": 2021,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "mips"
    ],
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSets": [],
    "measureSpecification": {}
  },
  {
    "title": "All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "measureId": "MCC1",
    "description": "Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service (FFS) beneficiaries 65 years and older with multiple chronic conditions (MCCs) who are assigned to the Accountable Care Organization (ACO)",
    "nationalQualityStrategyDomain": "Outcome",
    "measureType": "outcome",
    "primarySteward": "Centers for Medicare & Medicaid Services (CMS)",
    "metricType": "costScore",
    "firstPerformanceYear": 2021,
    "lastPerformanceYear": null,
    "isHighPriority": true,
    "isInverse": true,
    "isIcdImpacted": false,
    "isClinicalGuidelineChanged": false,
    "category": "quality",
    "isRegistryMeasure": false,
    "isRiskAdjusted": false,
    "icdImpacted": [],
    "clinicalGuidelineChanged": [],
    "allowedPrograms": [
      "app1"
    ],
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSets": [],
    "measureSpecification": {}
  },
  {
    "category": "cost",
    "title": "Medicare Spending Per Beneficiary (MSPB)",
    "description": "The risk-adjusted cost to Medicare for all Parts A and B services performed for an inpatient beneficiary as a result of a clinician's care during the period 3 days prior to the patient's hospital stay through 30 days after discharge.",
    "measureId": "MSPB_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-mspb-clinician.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Total Per Capita Costs (TPCC)",
    "description": "The overall, payment-standardized, annualized, risk-adjusted, and specialty-adjusted cost of care provided to beneficiaries attributed to their primary care clinicians.",
    "measureId": "TPCC_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-tpcc.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Routine Cataract Removal with Intraocular Lens (IOL) Implantation",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for routine cataract removal with IOL implantation during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from 60 days prior to the cataract removal procedure that triggers the episode through 90 days after the trigger.",
    "measureId": "COST_IOL_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-cataract.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Intracranial Hemorrhage or Cerebral Infarction",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries hospitalized for cerebral infarction or intracranial hemorrhage during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 90 days after the trigger.",
    "measureId": "COST_IHCI_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-ich-cva.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Knee Arthroplasty",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo an elective knee arthroplasty during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from 30 days prior to the knee arthroplasty that triggers the episode through 90 days after the trigger.",
    "measureId": "COST_KA_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-knee-arthro.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Elective Outpatient Percutaneous Coronary Intervention (PCI)",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from the PCI surgery that triggers the episode through 30 days after the trigger.",
    "measureId": "COST_EOPCI_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-op-pci.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Simple Pneumonia with Hospitalization",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries hospitalized with simple pneumonia during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 30 days after the trigger.",
    "measureId": "COST_SPH_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-pna-hosp.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Revascularization for Lower Extremity Chronic Critical Limb Ischemia",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from 30 days prior to the revascularization procedure that triggers the episode through 90 days after the trigger.",
    "measureId": "COST_CCLI_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-rleccli.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Screening/Surveillance Colonoscopy",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries who receive a screening/surveillance colonoscopy. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the screening/surveillance colonoscopy procedure that triggers the episode through 14 days after the trigger.",
    "measureId": "COST_SSC_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-ss-clnscpy.pdf"
    }
  },
  {
    "category": "cost",
    "title": "ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)",
    "description": "A clinician's risk-adjusted cost to Medicare for beneficiaries who present with STEMI, indicating complete blockage of a coronary artery, who emergently receive PCI as treatment during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 30 days after the trigger.",
    "measureId": "COST_STEMI_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2019,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": "simpleAverage",
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications//2020-12-14-mif-ebcm-stemi-pci.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Acute Kidney Injury Requiring New Inpatient Dialysis",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive their first inpatient dialysis service for acute kidney injury during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.",
    "measureId": "COST_AKID_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-aki-new-hd.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Elective Primary Hip Arthroplasty",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive an elective primary hip arthroplasty during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.",
    "measureId": "COST_PHA_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-el-ha.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Femoral or Inguinal Hernia Repair",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Femoral or Inguinal Hernia Repair episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgical procedure to repair a femoral or inguinal hernia during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.",
    "measureId": "COST_FIHR_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-fihr.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Hemodialysis Access Creation",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Hemodialysis Access Creation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.",
    "measureId": "COST_HAC_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-hd-access.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Inpatient COPD Exacerbation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient treatment for an acute exacerbation of COPD during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 60 days after the trigger.",
    "measureId": "COST_COPDE_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-ip-copd.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Lower Gastrointestinal Hemorrhage (groups only)",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lower Gastrointestinal Hemorrhage episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 35 days after the trigger.",
    "measureId": "COST_LGH_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-lgi-bleed.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgery for lumbar spine fusion during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.",
    "measureId": "COST_LSFDD_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-l-fusion.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Lumpectomy Partial Mastectomy, Simple Mastectomy",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lumpectomy, Partial Mastectomy, Simple Mastectomy episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo partial or total mastectomy for breast cancer during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.",
    "measureId": "COST_LPMSM_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-lump-mast.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Non-Emergent Coronary Artery Bypass Graft (CABG)",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Non-Emergent CABG episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a CABG procedure during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.",
    "measureId": "COST_NECABG_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-ne-cabg.pdf"
    }
  },
  {
    "category": "cost",
    "title": "Renal or Ureteral Stone Surgical Treatment",
    "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Renal or Ureteral Stone Surgical Treatment episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive surgical treatment for renal or ureteral stones during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 90 days prior to the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.",
    "measureId": "COST_RUSST_1",
    "metricType": "costScore",
    "firstPerformanceYear": 2020,
    "lastPerformanceYear": null,
    "isInverse": true,
    "overallAlgorithm": null,
    "submissionMethods": [
      "administrativeClaims"
    ],
    "measureSpecification": {
      "default": "https://qpp.cms.gov/docs/cost_specifications/2020-12-14-mif-ebcm-rn-stone.pdf"
    }
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_1",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0005",
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: How Well Providers Communicate",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_2",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0005",
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Patient’s Rating of Provider",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_3",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
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    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Access to Specialists",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_4",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
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  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Health Promotion and Education",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_5",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
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    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
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    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Shared Decision Making",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_6",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Health Status and Functional Status",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_7",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Care Coordination",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_8",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
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    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Courteous and Helpful Office Staff",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_9",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": "0005",
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
    ],
    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "category": "quality",
    "firstPerformanceYear": 2017,
    "lastPerformanceYear": null,
    "metricType": "cahps",
    "title": "CAHPS for MIPS SSM: Stewardship of Patient Resources",
    "description": "",
    "nationalQualityStrategyDomain": null,
    "measureType": "patientEngagementExperience",
    "measureId": "CAHPS_11",
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "nqfId": null,
    "isInverse": false,
    "strata": [],
    "isHighPriority": true,
    "isIcdImpacted": false,
    "primarySteward": "Agency for Healthcare Research & Quality",
    "submissionMethods": [
      "certifiedSurveyVendor"
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    "measureSets": [
      "generalPracticeFamilyMedicine"
    ],
    "allowedPrograms": [
      "mips",
      "app1"
    ],
    "isRegistryMeasure": false
  },
  {
    "measureId": "AAAAI17",
    "title": "Asthma Control: Minimal Important Difference Improvement",
    "description": "Percentage of patients aged 12 years and older whose asthma is not well-controlled as indicated by the Asthma Control Test, Asthma Control Questionnaire, or Asthma Therapy Assessment Questionnaire and who demonstrated a minimal important difference improvement upon a subsequent office visit during the 12-month reporting period. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Outcome Measure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "6273354"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI18",
    "title": "Penicillin Allergy: Appropriate Removal or Confirmation",
    "description": "Percentage of patients, regardless of age, with a primary diagnosis of penicillin or ampicillin/amoxicillin allergy, who underwent elective skin testing or antibiotic challenge that resulted in the removal of the penicillin or ampicillin/amoxicillin allergy label from the medical record if negative or confirmation of the penicillin or ampicillin/amoxicillin allergy label if positive. National Quality Strategy Domain: Communication and Care Coordination Outcome Measure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "6273354"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
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    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI2",
    "title": "Asthma: Assessment of Asthma Control – Ambulatory Care Setting",
    "description": "Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6273354"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI6",
    "title": "Documentation of Clinical Response to Allergen Immunotherapy within One Year",
    "description": "Percentage of patients aged 5 years and older who were evaluated for clinical improvement and efficacy within one year after initiating allergen immunotherapy AND assessment documented in the medical record. National Quality Strategy Domain: Communication and Care Coordination Process Measure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6273354"
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    "allowedPrograms": [
      "mips",
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      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAAAI8",
    "title": "Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year",
    "description": "Proportion of patients receiving subcutaneous allergen immunotherapy that contains at least one standardized extract (mite, ragweed, grass, and/or cat) who achieved the projected effective dose for all included standardized allergen extract(s) after at least one year of treatment. National Quality Strategy Domain: Effective Clinical Care Outcome Measure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
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    "primarySteward": "AAAAI QCDR - American Academy of Allergy, Asthma, and Immunology Quality Clinical Data Registry Powered by ArborMetrix",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6273354"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD10",
    "title": "Dermatitis – Improvement in Patient-Reported Itch Severity",
    "description": "The percentage of patients, aged 18 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient reported itch severity assessments performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
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      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD11",
    "title": "Skin Cancer Surgery: Post-Operative Complications",
    "description": "Percentage of patients, regardless of age, with a diagnosis of basal cell carcinoma, squamous cell carcinoma, or melanoma (including in situ disease) with a post-operative complication including infection, bleeding, or hematoma following a scalpel-based surgical procedure or Mohs surgery within 15 days of the procedure.",
    "nqfId": null,
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    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD12",
    "title": "Melanoma: – Appropriate Surgical Margins",
    "description": "Percentage of primary excisional surgeries for melanoma or melanoma in situ with Breslow depth and appropriate surgical margins per the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology- Melanoma (NCCN Guideline).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD6",
    "title": "Skin Cancer: Biopsy Reporting Time - Clinician to Patient",
    "description": "Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma or melanoma (including in situ disease) or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD7",
    "title": "Psoriasis: Screening for Psoriatic Arthritis",
    "description": "Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at each visit.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD8",
    "title": "Chronic Skin Conditions: Patient Reported Quality-of-Life",
    "description": "The percentage of patients aged 18 years and older with a chronic skin condition whose self-assessed quality-of-life was recorded at least once in the medical record within the measurement period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAD9",
    "title": "Psoriasis – Improvement in Patient-Reported Itch Severity",
    "description": "The percentage of patients, aged 18 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4649789"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN22",
    "title": "Quality of Life Outcome for Patients with Neurologic Conditions",
    "description": "Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN25",
    "title": "Pediatric Medication reconciliation",
    "description": "Percentage of pediatric patients who had a medication review at every encounter and a medication list present in the medical record.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8933551"
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    "allowedPrograms": [
      "mips",
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN26",
    "title": "Activity counseling for back pain",
    "description": "Percentage of patients 18 to 65 years of age who were counseled to remain active and exercise or were referred to physical therapy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8933551"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN28",
    "title": "Diabetes/Pre-Diabetes Screening for Patients with DSP",
    "description": "Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for diabetes (e.g. fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered when seen for an initial evaluation for distal symmetric polyneuropathy and if screen positive referred to endocrinology or PCP.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8933551"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN29",
    "title": "Comprehensive Epilepsy Care Center Referral or Discussion for Patients with Epilepsy",
    "description": "Percentage of patients who were referred or had a discussion of evaluation at a comprehensive\nepilepsy care center*.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN30",
    "title": "Migraine Preventive Therapy Management",
    "description": "Percentage of patients aged 6 years and older with a diagnosis of migraine whose migraine frequency is greater than or equal to 6 days per month/4 attacks per month who were managed with an evidence-based preventive migraine therapy, including therapies prescribed by another clinician.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN31",
    "title": "Acute Treatment Prescribed for Cluster Headache",
    "description": "Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed an acute treatment, including treatments prescribed by a different clinician.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN32",
    "title": "Preventive Treatment Prescribed for Cluster Headache",
    "description": "Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed short-term and/or long-term preventive treatment, including treatments prescribed by a different clinician.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN33",
    "title": "Fatigue Screening and Follow-Up for Patients with MS",
    "description": "Percentage of patients with MS who were screened for fatigue in past 12 months, and if\nscreening positive were provided appropriate follow-up.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN34",
    "title": "Patient reported falls and plan of care",
    "description": "Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN5",
    "title": "Medication Prescribed For Acute Migraine Attack",
    "description": "Percentage of patients age 6 years and older with a diagnosis of migraine who were prescribed a guideline recommended or FDA approved/cleared treatment for acute migraine attacks within the measurement period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN8",
    "title": "Exercise and Appropriate Physical Activity Counseling for Patients with MS",
    "description": "Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate physical activity for patients with MS in the past 12 months.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAN9",
    "title": "Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease",
    "description": "Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified had appropriate follow-up.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Axon Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "8933551"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO12",
    "title": "Tympanostomy Tubes: Topical Ear Drop Monotherapy Acute Otorrhea",
    "description": "Percentage of patients age 6 months to 12 years of age at the time of the visit with a current diagnosis of an uncomplicated acute tympanostomy tube otorrhea (TTO) who were prescribed or recommended to use topical antibiotic eardrops and NOT prescribed systemic (IV or PO) antibiotics for acute tympanostomy tube otorrhea.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO13",
    "title": "Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan (Inverse Measure)",
    "description": "Percentage of patients age 16 years and older with a new onset diagnosis of Bell’s palsy within the past 3 months who had a magnetic resonance imaging (MRI) or a computed tomography scan (CT) of the internal auditory canal, head, neck or brain ordered for the primary diagnosis of Bell’s palsy.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO16",
    "title": "Age-related Hearing Loss: Audiometric Evaluation",
    "description": "Percentage of patients age 60 years and older who failed a hearing screening and/or who report suspected hearing loss who received, were ordered, or were referred for comprehensive audiometric evaluation within 4 weeks the office visit.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO20",
    "title": "Tympanostomy Tubes: Hearing Test",
    "description": "Percentage of patients age 6 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion and received a hearing test within 6 months prior to tympanostomy tube insertion",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO21",
    "title": "Otitis Media with Effusion: Hearing Test for Chronic OME > 3 months",
    "description": "Percentage of patients age 6 months to 12 years of age at the time of the visit with a diagnosis of otitis media with effusion including chronic serous, mucoid, or nonsuppurative otitis media with effusion of ≥3 months duration who had audiometry performed, ordered or who were referred for an audiometric evaluation.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO23",
    "title": "Allergic Rhinitis: Intranasal Corticosteroids or Oral Antihistamines",
    "description": "Percentage of patients age 2 years and older with allergic rhinitis who are offered intranasal corticosteroids (INS) or non-sedating oral antihistamines",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO24",
    "title": "Allergic Rhinitis: Avoidance of Leukotriene Inhibitors",
    "description": "Percentage of patients age 2 years and older patients with allergic rhinitis who do not receive leukotriene inhibitors",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO29",
    "title": "Quality of Life for Patients with Neurotology Disorders",
    "description": "Percentage of neurotology patients whose most recent Quality of Life scores were maintained or improved during the measurement period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO31",
    "title": "Otitis Media with Effusion (OME): Avoidance of Inappropriate Use of Medications",
    "description": "Percentage of patients age 2 months through 12 years with a diagnosis of otitis media with effusion who were not prescribed or recommended the use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO32",
    "title": "Standard BPPV Management",
    "description": "Percentage of BPPV patients who received vestibular testing, imaging, and antihistamine or benzodiazepine medications (Inverse Measure).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO34",
    "title": "Dysphonia: Postoperative Laryngeal Examination",
    "description": "Percentage of patients age 18 years and older who were diagnosed with new onset dysphonia within 2 months after a thyroidectomy who received or were referred for a laryngeal examination to examine vocal fold/cord mobility, and, if abnormal vocal fold mobility is identified, receive a plan of care for voice rehabilitation.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "AAO35",
    "title": "Benign Positional Paroxysmal Vertigo (BPPV): Dix-Hallpike and Canalith Repositioning",
    "description": "Percentage of patients with BPPV who had a Dix-Hallpike maneuver performed AND who had therapeutic canalith repositioning procedure (CRP) performed or who were referred for physical therapy or to a provider who can perform CRP if identified with posterior canal BPPV",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry, Axon Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868",
      "8933551"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AAO36",
    "title": "Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Adults and Children",
    "description": "Percentage of patients aged 6 months and older with a diagnosis of otitis media with effusion who are seen 2 to 8 weeks after tympanostomy tube surgery and otitis media with effusion is resolved.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8365868"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "AASM1",
    "title": "Pediatric OSA: Objective Assessment of Positive Airway Pressure Therapy Adherence",
    "description": "Proportion of patients aged < 18 years diagnosed with OSA that were prescribed positive airway pressure therapy and had documentation of objectively measured adherence to positive airway pressure therapy within 3 months of starting therapy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Sleep Medicine Clinical Data Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4076932"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "AASM2",
    "title": "Pediatric OSA: Objective Assessment of OSA Signs and Symptoms in Children with Complex Medical Conditions",
    "description": "Proportion of patients aged < 18 years with complex medical conditions known to be at high risk for OSA and with signs and symptoms of OSA that underwent a PSG or were referred to a sleep specialist, otolaryngologist, or other specialist experienced in evaluation and management of OSA in children",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Sleep Medicine Clinical Data Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4076932"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AASM3",
    "title": "Adult OSA: Screening for Adult OSA by Primary Care Physicians",
    "description": "All patients aged 18 years and older at high risk for obstructive sleep apnea (OSA) with documentation of screening for OSA using an appropriate standardized tool at least every 12 months AND in whom a recommended follow-up plan is documented based upon the result of the screening",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Sleep Medicine Clinical Data Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4076932"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABFM11",
    "title": "Person-Centered Primary Care Measure Performance Measure (PCPCM PRO-PM)",
    "description": "The Person-Centered Primary Care Measure Performance Measure (PCPCM PRO-PM) utilizes the PCPCM PROM (a comprehensive and parsimonious set of 11 patient-reported items) to assess the broad scope of primary care: accessibility; comprehensive, whole person focus; integration of care across acute and chronic illness, prevention, mental health, and life events; coordinating care in a fragmented system; knowing the patient as a person; developing a relationship through key life events; advocacy; providing care in a family context; providing care in a community context; goal-oriented care; and, disease, illness, and prevention management. The PCPCM PRO-PM performance measure, generated from the patient reported instrument, goes beyond usual patient experience or satisfaction measures, to use the on-the-ground view of patients to assess elements of primary care missed by usual measures and gives clinicians a distinctive and comprehensive view from a patient’s perspective.\n\n1. My practice makes it easy for me to get care.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n2. My practice is able to provide most of my care.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all \n3. In caring for me, my doctor considers all the factors that affect my health.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n4. My practice coordinates the care I get from multiple places.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n5. My doctor or practice knows me as a person.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n6. My doctor and I have been through a lot together.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n7. My doctor or practice stands up for me.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n8. The care I get takes into account knowledge of my family.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n9. The care I get in this practice is informed by knowledge of my community.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n10. Over time, my practice helps me to stay healthy.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all\n11. Over time, my practice helps me to meet my goals.\nDefinitely\t\tMostly\t\tSomewhat\t\tNot at all",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ABFM PRIME",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4849508"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABFM9",
    "title": "Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure",
    "description": "Bice-Boxerman Continuity of Care Primary Care Physician Measure. \n\nAt a patient-level, Bice-Boxerman Continuity of Care Primary Care Physician Measure is a measure that considers the dispersion of primary care visits across providers, such that patients with higher scores have most of their primary care visits to the same provider or a small number of providers while those lower scores see a larger number providers. Formally, an individual Bice-Boxerman Continuity of Care score is calculated as follows:\n\nBice-Boxerman Continuity of Care =(∑_(i=1)^k n_i^2 -N)/(N(N-1)) (1)\n\nwhere k is the number of providers, n_i is the number of visits to provider i, and N is the total number of visits. (Note that it is necessary that the patient has at least two visits.)\nWe will calculate the physician-level continuity measure for all patients as follows: \n \nBice-Boxerman Continuity of Care-PC=(∑_1^k 〖((Bice-Boxerman Continuity of Care)(n_k ))〗)/(N*(n_k)) (2)\n\nWhere Bice-Boxerman Continuity of Care is the individual patient continuity score, n is number of total primary care visits for patient k during the study period, and N is the total number of patients seen by the physicians during the study period. This approach gives greater weight to patients with more visits.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ABFM PRIME",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4849508"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG40",
    "title": "Hypotension Prevention After Spinal Placement for Elective Cesarean Section",
    "description": "Percentage of patients, who present for elective Caesarean section under spinal anesthesia who have phenylephrine infusions started prophylactically to prevent hypotension.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ABG QCDR",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5551268"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG41",
    "title": "Upper Extremity Nerve Blockade in Shoulder Surgery",
    "description": "Percentage of patients who undergo shoulder arthroscopy or shoulder arthroplasty who have an upper extremity nerve blockade performed before or immediately after the procedure.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ABG QCDR",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5551268"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ABG42",
    "title": "Known or Suspected Difficult Airway Mitigation Strategies",
    "description": "Percentage of patients with a known or suspected difficult airway who undergo a planned general endotracheal anesthetic that have both a second provider present at the induction and placement of the endotracheal tube and have difficult airway equipment in the room prior to the induction.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ABG QCDR",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5551268"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPIN11",
    "title": "Heart Failure: Patient Self Care Education",
    "description": "Percentage of patients aged >=18 years with a diagnosis of heart failure who were provided with self-care education on >=3 elements of education during >=1 visit within a 12-month period",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The PINNACLE Registry and Diabetes Collaborative Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9682065"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPIN7",
    "title": "Peripheral Artery Disease: Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk",
    "description": "Percentage of Patients 18-75 years of age with PAD who were offered moderate-to-high intensity statin",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The PINNACLE Registry and Diabetes Collaborative Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "9682065"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACCPIN8",
    "title": "Hypertension Control (Stage 1 or 2)",
    "description": "Proportion of patients with hypertension who had adequately controlled blood pressure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The PINNACLE Registry and Diabetes Collaborative Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "9682065"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP19",
    "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older",
    "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP21",
    "title": "Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding",
    "description": "Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP22",
    "title": "Appropriate Emergency Department Utilization of CT for Pulmonary Embolism",
    "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP25",
    "title": "Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED and discharged who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP30",
    "title": "Sepsis Management: Septic Shock: Lactate Clearance Rate of ≥ 10%",
    "description": "Percentage of emergency department visits for patients aged 18 years and older with septic shock resulting in hospital admission who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of ≥ 10% during the emergency department visit",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP31",
    "title": "Appropriate Foley catheter use in the emergency department",
    "description": "Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP48",
    "title": "Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation",
    "description": "Percentage of emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an order for all the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5133825",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP50",
    "title": "ED Median Time from ED arrival to ED departure for all Adult Patients",
    "description": "Time (in minutes) from ED arrival to ED departure for all Adult Patients",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry), ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5133825",
      "1718371"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "ACEP51",
    "title": "ED Median Time from ED arrival to ED departure for all Pediatric Patients",
    "description": "Time (in minutes) from ED arrival to ED departure for all Pediatric Patients",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry), ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5133825",
      "1718371"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "ACEP52",
    "title": "Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain",
    "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT or MRI of the Lumbar Spine ordered by an emergency care provider, regardless of discharge disposition, presenting with acute, non-complex low back pain.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5133825",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP53",
    "title": "Appropriate Use of Imaging for Recurrent Renal Colic",
    "description": "Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5133825",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACEP54",
    "title": "Appropriate Utilization of FAST Exam in the Emergency Department",
    "description": "Percentage of emergency department visits for patients aged 18 years and older presenting with hemodynamically unstable blunt abdominal trauma (blunt trauma and a systolic blood pressure <90 mmHg or heart rate >120 bpm) or penetrating thoracoabdominal trauma who had a FAST exam ordered and/or performed during the emergency department visit",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5133825"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACEP55",
    "title": "Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years",
    "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as high risk according to the PECARN prediction rules for traumatic brain injury",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5133825"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACEP56",
    "title": "Follow-Up Care Coordination Documented in Discharge Summary",
    "description": "Percentage of patients aged 18 years and older for which follow-up care coordination was documented in Hospital Discharge Summary",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5133825"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACEP57",
    "title": "Avoidance of Opioid therapy for migraine, low back pain, dental pain",
    "description": "All ED encounters for patients aged 18 years and older with diagnosis of migraine or low back pain or dental pain who were prescribed or administered Opioids or Opiates",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5133825"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACEP58",
    "title": "Appropriate Treatment for Adults with Upper Respiratory Infection (URI)",
    "description": "Percentage of adults 18 years and older who were diagnosed with upper respiratory infection (URI) and were dispensed or administered an antibiotic prescription on or up to three days after the ED encounter",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5133825"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACMS2",
    "title": "Closing the Mohs Surgery Referral Loop: Transmission of Surgical Report",
    "description": "Percentage of Mohs micrographic surgery cases or Mohs surgical defect reconstruction cases for which the reconstruction was performed by a different surgeon than the Mohs surgeon, regardless of patient age, for which a report is sent from the treating provider to the referring provider within 30 days.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MohsAIQ",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6621356",
      "6859936"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACMS3",
    "title": "Antibiotic Prophylaxis for High Risk Cardiac / Orthopedic Cases prior to Mohs micrographic surgery - Prevention of Overuse",
    "description": "Percentage of cases of Mohs surgery in which preoperative prophylactic antibiotics were provided for which the patient had cardiac / orthopedic prophylaxis indications for preoperative antibiotics.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MohsAIQ",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6859936"
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    "allowedPrograms": [
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      "pcf"
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    "lastPerformanceYear": null,
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    "isRegistryMeasure": true,
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACMS4",
    "title": "Surgical Site Infection Rate - Mohs Micrographic Surgery",
    "description": "Percentage of cases of Mohs surgery that develop a surgical site infection. This measure is to be reported each time a procedure for a Mohs surgery is performed whether or not a surgical site infection develops during the performance period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MohsAIQ",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6859936"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACMS5",
    "title": "Documentation of High-Risk Squamous Cell Carcinoma Stage in Mohs Micrographic Surgery Record",
    "description": "Percentage of Mohs surgery cases for high risk cutaneous squamous cell carcinoma (SCC) of the head and neck for which America Joint Committee on Cancer (AJCC) 8th edition staging1, that was documented in the medical record. For these purposes high-risk is defined as a tumor stage greater than T2.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MohsAIQ",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACMS8",
    "title": "Limit quantity of opioids prescribed for pain management in patients following Mohs micrographic surgery",
    "description": "Percentage of patients prescribed opioids for pain management following Mohs surgery who received ten or fewer pills.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MohsAIQ",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACQR12",
    "title": "ABCDEF Bundle - Early mobility for ICU patients",
    "description": "Patients admitted to the intensive care unit (ICU) for > or = 4 days should be included in an early mobility program (E of ABCDEF Bundle) to improve their recovery process.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Acute Care Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4672586"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACQR13",
    "title": "Sepsis: Hour One bundle",
    "description": "Surviving Sepsis Campaign's Hour One bundle initiation in patients with Sepsis and acute organ dysfunction",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Acute Care Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4672586"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACQR15",
    "title": "Use of a risk stratification tool in patients with CAP",
    "description": "Documentation of CURB-65 score should guide the admission decision (1 point each for Confusion, BUN>19, Resp rate >30, SBP <90 or DBP<60, Age >=65) for all patients with Community Acquired Pneumonia). PSI/PORT is more complex than CURB-65, and assigns various point values to age, gender, nursing home residence, presence of neoplastic disease, CHF, liver disease, cerebrovascular disease, CKD, altered mental status, hypotension (<90 mmHg), hypothermia or high fever, tachycardia >125, BPM, Acidosis <7.35, BUN>30, hyponatremia <130, Hct <30, pO2<60 mmHg, and pleural effusion.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Acute Care Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4672586",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACQR16",
    "title": "COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation",
    "description": "Patients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapnic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available; and patients admitted with AHA Class D heart failure and/or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Acute Care Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4672586"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACQR3",
    "title": "COPD: Steroids for no more than 5 days in COPD Exacerbation",
    "description": "Patients should receive no more than 5 days of steroids in treatment for COPD Exacerbation from all sources and routes. Sources may include outpatient, Emergency Department, and Inpatient/Observation treatment. i.e. Full course of steroids not to exceed 7 days.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Acute Care Quality Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "4672586"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACQR9",
    "title": "Use of ACE-I or ARB and beta blockade in CHF",
    "description": "Ace I or ARBs AND 1 of [3 beta blockers proven to reduce mortality] (bisoprolol, carvedilol, sustained release metoprolol) are recommended in HFrEF and current or prior symptoms of CHF",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Acute Care Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4672586",
      "1725296"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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    "nqfEMeasureId": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
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      "registry"
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  },
  {
    "measureId": "ACR10",
    "title": "Hepatitis B Safety Screening",
    "description": "If a patient is newly initiating biologic or new synthetic DMARD therapy, then the medical record should indicate appropriate screening for hepatitis B in the preceding 12 month period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5598408"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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      "registry"
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  },
  {
    "measureId": "ACR12",
    "title": "Disease Activity Measurement for Patients with PsA",
    "description": "If a patient has psoriatic arthritis, then disease activity using a standardized measurement tool should be assessed at >=50% of encounters for PsA.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5598408"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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      "registry"
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  },
  {
    "measureId": "ACR14",
    "title": "Gout: Serum Urate Target",
    "description": "The percentage of patients aged 18 and older with at least one clinician encounter (including telehealth) during the measurement period and a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.0 mg/dL.",
    "nqfId": "2549e",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5598408"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
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    "metricType": "registrySinglePerformanceRate",
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      "registry"
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  },
  {
    "measureId": "ACR15",
    "title": "Safe Hydroxychloroquine Dosing",
    "description": "If a patient is using hydroxychloroquine, then the average daily dose should be ≤5 mg/kg",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5598408"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACR16",
    "title": "Rheumatoid Arthritis Patients with Low Disease Activity or Remission",
    "description": "The proportion of individuals with RA who have low disease activity or are in remission based on the last recorded disease activity score as assessed using an ACR-preferred tool in the measurement year.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5598408"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACRAD15",
    "title": "Report Turnaround Time: Radiography",
    "description": "Mean radiography report turnaround time (RTAT). (Does not include mammography.)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5303416"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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    "nqfEMeasureId": null,
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    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "ACRAD16",
    "title": "Report Turnaround Time: Ultrasound (Excluding Breast US)",
    "description": "Mean Ultrasound report turnaround time (RTAT)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD17",
    "title": "Report Turnaround Time: MRI",
    "description": "Mean MRI report turnaround time (RTAT)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD18",
    "title": "Report Turnaround Time: CT",
    "description": "Mean CT report turnaround time (RTAT)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD19",
    "title": "Report Turnaround Time: PET",
    "description": "Mean PET report turnaround time (RTAT)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD25",
    "title": "Report Turnaround Time: Mammography",
    "description": "Mean mammography report turnaround time (RTAT).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD34",
    "title": "Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)",
    "description": "Weighted average of 3 former QCDR measures, ACRad 31, ACRad 32, Acrid 33.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "abdomen",
        "description": "Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level"
      },
      {
        "name": "chest",
        "description": "Percent of CT Chest exams without contrast (single phase scan) for which Dose"
      },
      {
        "name": "head",
        "description": "Percent of CT Head/brain exams without contrast (single phase scan) for which Dose"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD36",
    "title": "Incidental Coronary Artery Calcification Reported on Chest CT",
    "description": "Percentage of final reports for male patients aged 18 years through 50 and female patients aged 18 through 65 years undergoing noncardiac noncontrast chest CT exams or with and without contrast chest CT exams that note presence or absence of coronary artery calcification or not evaluable",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD37",
    "title": "Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism",
    "description": "Percentage of final reports for patients aged 18 years and older undergoing CT pulmonary angiography (CTPA) with a finding of PE that specify the branching order level of the most proximal level of embolus (i.e. main, lobar, interlobar, segmental, sub segmental)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD38",
    "title": "Use of Low Dose Cranial CT or MRI Examinations for Patients with Ventricular Shunts",
    "description": "Percentage of patients aged less than 18 years with a ventricular shunt undergoing cranial imaging exams to evaluate for ventricular shunt malfunction undergoing either low dose cranial CT exams or MRI",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD39",
    "title": "Use of Low Dose CT Studies for Adults with Suspicion of Urolithiasis or Nephrolithiasis",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of urolithiasis or nephrolithiasis undergoing CT imaging exams of the abdomen or pelvis to evaluate for urologic stones undergoing only low-dose CT exams of the abdomen or pelvis without intravenous contrast",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD40",
    "title": "Use of Structured Reporting in Prostate MRI",
    "description": "Percentage of final reports for male patients aged 18 years and older undergoing prostate MRI for prostate cancer screening or surveillance that include reference to a validated scoring system such as Prostate Imaging Reporting and Data System (PI-RADS)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD41",
    "title": "Use of Quantitative Criteria for Oncologic FDG PET Imaging",
    "description": "Percentage of final reports for all patients, regardless of age, undergoing non-CNS oncologic FDG PET studies that include at a minimum:\na. Serum glucose (e.g., finger stick at time of injection)\nb. Uptake time (interval from injection to initiation of imaging)\nc. One reference background (e.g., volumetric normal liver or mediastinal blood pool) SUV measurement, along with description of the SUV measurement type (e.g., SUVmax) and normalization method (e.g., BMI)\nd. At least one lesional SUV measurement OR diagnosis of \"no disease-specific abnormal uptake\"",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ACRAD42",
    "title": "Surveillance Imaging for Liver Nodules <10mm in Patients at Risk for Hepatocellular Carcinoma (HCC)",
    "description": "Percentage of final ultrasound reports with findings of liver nodules < 10 mm for patients aged 18 years and older with a diagnosis of hepatitis B or cirrhosis undergoing screening and/or surveillance imaging for hepatocellular carcinoma with a specific recommendation for follow-up ultrasound imaging in 3-6 months based on radiological findings",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American College of Radiology National Radiology Data Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5303416"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AHSQC10",
    "title": "Ventral Hernia Repair: Pain and Functional Status Assessment",
    "description": "Percentage of patients aged 18 years and older who have undergone ventral hernia repair and who completed baseline and 30 day follow-up patient-reported functional status assessments, and achieved at least a 10% improvement in functional status score from baseline.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Abdominal Core Health Quality Collaborative (ACHQC) Foundation",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "9986051"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "overall",
        "description": "Patients who achieved at least a 10% improvement in functional status score from baseline."
      },
      {
        "name": "followup",
        "description": "Patients who completed baseline and 30 day follow-up patient-reported functional status assessments,"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AHSQC6",
    "title": "Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period",
    "description": "Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal. \n\nThis measure is reported as three performance rates stratified by hernia width: \n1) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate)\n2) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm\n3) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Abdominal Core Health Quality Collaborative (ACHQC) Foundation",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "9986051"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "overall",
        "description": "All patients in the cohort who have undergone ventral hernia repair with myofascial release with 30 day postoperative follow up"
      },
      {
        "name": "<=10cm",
        "description": "All patients in the cohort who have undergone ventral hernia repair with myofascial release with 30 day postoperative follow up with hernia width < 10cm"
      },
      {
        "name": ">10cm",
        "description": "All patients in the cohort who have undergone ventral hernia repair with myofascial release with 30 day postoperative follow up with hernia width > 10cm"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AJRR3",
    "title": "Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy",
    "description": "Percentage of patients undergoing a hip arthroplasty with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g. NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AJRR4",
    "title": "Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk Evaluation",
    "description": "Percentage of patients undergoing a hip arthroplasty who are evaluated for the presence or absence of cardiovascular risk factors within 30 days prior to the procedure (e.g. history of deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), arrhythmia, and stroke).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AJRR6",
    "title": "Hip/Knee Arthroplasty: Unplanned Readmission within 90 Days Following the Primary Procedure",
    "description": "Percentage of patients 18+ who underwent a primary Total Hip Arthroplasty or Total Knee Arthroplasty and who had an unplanned 90-day readmission.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AJRR7",
    "title": "Hip/Knee Replacement: Postoperative Ambulation",
    "description": "Adult patients 18+ undergoing a total hip or total knee replacement who ambulated postoperatively.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI18",
    "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure",
    "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "6394618",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI48",
    "title": "Patient-Reported Experience with Anesthesia",
    "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. \n\nThis measure will consist of two performance rates:\n\nAQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care \nAQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care\n\nNOTE: The measure requires that a valid survey, as defined in the numerator of AQI48a, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI48b, a minimum number of 20 surveys with the mandatory question completed must be reported. ** In order to be scored on this measure, clinicians must report BOTH AQI48a AND AQI48b.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "6394618",
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "surveyed",
        "description": "The first performance rate, AQI48a, describes the percentage of surgical patients who receive a survey of their experience with anesthesia care."
      },
      {
        "name": "overall",
        "description": "The second performance rate, AQI48b, describes the percentage of surgical patients who report a positive experience with anesthesia care."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI49",
    "title": "Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite",
    "description": "Percentage of patients, aged 18 years and older, who undergo a cardiac operation using cardiopulmonary bypass for whom selected blood conservation strategies were used.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "5551268",
      "6169123",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI55",
    "title": "Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients",
    "description": "Percentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for ≥48 hours and who received critical care services who have documentation by managing physician of 1) attempted or actual identification of a surrogate decision maker, 2) an advance directive, and 3) the patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admission",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "5551268",
      "6169123",
      "4757099",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI56",
    "title": "Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)",
    "description": "Percentage of patients, regardless of age, that undergo primary total knee arthroplasty for whom neuraxial anesthesia and/or a peripheral nerve block is performed",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "9881603",
      "6394618",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI57",
    "title": "Safe Opioid Prescribing Practices",
    "description": "Percentage of patients, aged 18 years and older, prescribed opioid medications for longer than six weeks’ duration for whom ALL of the following opioid prescribing best practices are followed:\n\n1. Chemical dependency screening (includes laboratory testing and/or questionnaire) within the immediate 6 months prior to the encounter\n2. Co-prescription of naloxone or documented discussion regarding offer of Naloxone co-prescription, if prescription is ≥50 MME/day\n3. Non co-prescription of benzodiazepine medications by prescribing pain physician and documentation of a discussion with patient regarding risks of concomitant use of benzodiazepine and opioid medications.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "4757099",
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI62",
    "title": "Obstructive Sleep Apnea: Patient Education",
    "description": "Percentage of patients aged 18 years or older, who undergo an elective procedure requiring anesthesia services who are screened for obstructive sleep apnea (OSA) AND, if positive, have documentation that they received education regarding their risk for OSA prior to PACU discharge",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "6394618",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI65",
    "title": "Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass",
    "description": "Percentage of patients, aged 18 years and older, undergoing a procedure using cardiopulmonary bypass who did not have a documented intraoperative pulmonary artery, oropharyngeal, or nasopharyngeal temperature ≥37.0 degrees Celsius during the period of cardiopulmonary bypass",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "6394618",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI67",
    "title": "Consultation for Frail Patients",
    "description": "Percentage of patients aged 70 years or older, who undergo an inpatient procedure requiring anesthesia services and have a positive frailty screening result who receive a multidisciplinary consult or care during the hospital encounter",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "6394618",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI68",
    "title": "Obstructive Sleep Apnea: Mitigation Strategies",
    "description": "Percentage of patients aged 18 years or older, who undergo an elective procedure requiring anesthesia services who are screened for obstructive sleep apnea (OSA) AND, if positive, for whom two or more selected mitigation strategies was used prior to PACU discharge",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5551268",
      "6169123",
      "6775913",
      "6394618",
      "1284980",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI69",
    "title": "Intraoperative Antibiotic Redosing",
    "description": "Percentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision (if fluoroquinolone or vancomycin, two hours) and undergo a procedure greater than two hours duration who received intraoperative antibiotic redosing at a maximum interval of two half-lives of the selected prophylactic antibiotic.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6169123",
      "6775913",
      "4757099",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI70",
    "title": "Prevention of Arterial Line-Related Bloodstream Infections",
    "description": "Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial catheter for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.\n\nThis measure will consist of two performance rates: \n\na.\t Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the brachial, radial, posterior tibial or dorsalis pedis artery for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed\n\nb.\t Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the femoral or axillary artery for whom the arterial line was inserted with all indicated elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound technique is followed\n\nThe overall measure score will be calculated as an average of the performance rates of part A and part B.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6169123",
      "6775913",
      "4757099",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI71",
    "title": "Ambulatory Glucose Management",
    "description": "Percentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period.\n\nThe measure consists of four performance rates:\n\na.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery whose blood glucose level is tested prior to the start of anesthesia\n\nb.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level >180 mg/dL (10.0 mmol/L) who received insulin prior to anesthesia end time\n\nc.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who received insulin perioperatively and who received a follow-up blood glucose level check following the administration of insulin and prior to discharge\n\nd.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level >180 mg/dL (10.0 mmol/L) who received education on managing their glucose in the postoperative period prior to discharge",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6169123",
      "6775913",
      "4757099",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQI72",
    "title": "Perioperative Anemia Management",
    "description": "Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6169123",
      "6775913",
      "4757099",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA14",
    "title": "Stones: Inappropriate Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment",
    "description": "Percentage of patients who underwent inappropriate repeat SWL within 6 months of initial procedure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association Quality (AQUA) Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "8758330"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA15",
    "title": "Stones: Urinalysis Performed Before Surgical Stone Procedures",
    "description": "Percentage of patients with a documented urinalysis 30 days before surgical stone procedures",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association Quality (AQUA) Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "8758330"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA16",
    "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease",
    "description": "Percentage of patients with T1 disease, that had a second TURBT within 6 weeks of the initial TURBT",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association Quality (AQUA) Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "8758330"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA18",
    "title": "Non-Muscle Invasive Bladder Cancer: Early Surveillance Cystoscopy for Non-Muscle Invasive Bladder Cancer",
    "description": "Percentage of patients who receive surveillance cystoscopy within 4 months of TURBT for bladder cancer",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association Quality (AQUA) Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "8758330"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA26",
    "title": "Benign Prostate Hyperplasia (BPH): Inappropriate Lab & Imaging Services for Patients with BPH",
    "description": "Percentage of patients with new diagnosis of BPH who had a creatinine lab order placed or had a CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association Quality (AQUA) Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8758330"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "AQUA8",
    "title": "Hospital admissions/complications within 30 days of TRUS Biopsy",
    "description": "Percentage of patients who had TRUS biopsy performed who had ≥24h after the biopsy): infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Urological Association Quality (AQUA) Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "8758330"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS10",
    "title": "Patient Satisfaction with Information Provided during Breast Reconstruction",
    "description": "Percentage of patients aged 18 years and older who had breast reconstruction who reported a score of 65 or higher on the BREAST-Q Satisfaction with Information scale, within 120 days of the procedure. \n\nThis measure is reported as three rates stratified by procedure:\n•Reporting Criteria 1: Implant Breast Reconstruction Procedures \n•Reporting Criteria 2: Autologous Breast Reconstruction Procedures\n•Total Rate: All breast reconstruction Procedures",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ASPS TOPS-QCDR",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "6621356"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "implant",
        "description": "Implant-based breast reconstruction,"
      },
      {
        "name": "autologous",
        "description": "Autologous breast reconstruction,"
      },
      {
        "name": "overall",
        "description": "All breast reconstruction"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS16",
    "title": "Airway Assessment for patients undergoing Rhinoplasty",
    "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure for whom the nasal airway was assessed with physical examination via anterior rhinoscopy and/or speculum examination (lighted or not) and status of the septum, turbinates, and valves was documented.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry, ASPS TOPS-QCDR",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868",
      "6621356"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS17",
    "title": "Patient Satisfaction with Rhinoplasty Procedure",
    "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure who demonstrated improvement* in functional and/or aesthetic satisfaction using a validated patient satisfaction tool (such as SCHNOS, NOSE, SNOT, RHINO) within a year following their procedure. \n*pre-test and post-test scores must be documented in the patient record",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry, ASPS TOPS-QCDR",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868",
      "6621356"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS18",
    "title": "Shared-decision making for post-operative management of discomfort following Rhinoplasty",
    "description": "Percentage of patients aged 15 years and older who had a rhinoplasty procedure who had documentation of a pre-operative shared-decision making strategy for multi-modal post-operative management of discomfort.\nDefinitions: Documentation of discussion of at least two mechanisms of pain management from the following terms or phrases (one term or phrase from each list) will meet the measure:\nList 1) Non-opioid analgesics: Non-narcotic/Non-opioid, Acetaminophen/Tylenol, Cox-II inhibitor (Celecoxib), Local/Marcaine/Block, Anxiolytic, Tramadol, NSAID/ibuprofen\n\nList 2) Non-systemic: Ice/Cooling, Elevation, Rest, Mindfulness, Meditation",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry, ASPS TOPS-QCDR",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8365868",
      "6621356"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS22",
    "title": "Coordination of Care for Anticoagulated Patients Undergoing Reconstruction After Skin Cancer Resection",
    "description": "Percentage of patients aged 18 and older on prescribed anticoagulation medication who underwent reconstruction after skin cancer resection (in any setting) and preoperative modification* to their anticoagulant(s) regimen, who had documentation of coordinated care** prior to their procedure.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ASPS TOPS-QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8365868",
      "6621356",
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS24",
    "title": "Visits to the ER or Urgent Care Following Reconstruction After Skin Cancer Resection",
    "description": "Part 1: Percentage of patients aged 18 and older who underwent reconstruction after skin cancer resection who were asked* within 30 days of their procedure whether they visited the ER or Urgent Care within 7 days of their procedure, for a reason related to the reconstruction after skin cancer resection surgery.\n\nPart 2: Percentage of patients, aged 18 and older who underwent reconstruction after skin cancer resection and were asked within 30 days of the procedure about visiting the ER, who visited the ER or Urgent Care within 7 days of their procedure for a reason related to the reconstruction after skin cancer resection surgery. (only Part 2 is intended to be reported for accountability, but Part 1 must be completed)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ASPS TOPS-QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8365868",
      "6621356",
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS26",
    "title": "Patient Satisfaction with Information Prior to Facial Reconstruction After Skin Cancer Resection Procedures",
    "description": "Percentage of patients aged 18 and older who underwent facial reconstruction after skin cancer resection who responded to the (6 question) Face-Q Satisfaction with Information: Appearance Module within 60 days of the procedure and scored 15 (52%) or higher or if scored lower than 15 (52%) there is documentation of a provider call to the patient or follow-up visit within 30 days of completion of the tool",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ASPS TOPS-QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8365868",
      "6621356"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS27",
    "title": "Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures",
    "description": "Percentage of procedures in patients aged 18 and older with a diagnosis of skin cancer who underwent intermediate layer or complex linear closure or reconstruction after skin cancer resection in the office-based* setting who were prescribed post-operative systemic antibiotics to be taken immediately following reconstruction surgery (inverse measure)\n\nThis measure is stratified by intermediate layer or complex linear closure or reconstructive procedures.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MohsAIQ, AAD’s DataDerm™, ASPS TOPS-QCDR",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4649789",
      "8365868",
      "6621356",
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "resection",
        "description": "Strata 1: Intermediate layer or complex linear closures after skin cancer resection"
      },
      {
        "name": "reconstruction",
        "description": "Strata 2: Reconstruction after skin cancer resection"
      },
      {
        "name": "overall",
        "description": "Strata 3: FOR REPORTING"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS28",
    "title": "Continuation of Anticoagulation Therapy in the Office-based Setting for Closure and Reconstruction After Skin Cancer Resection Procedures",
    "description": "Percentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, on prescribed anticoagulation therapy, who had intermediate layer and/or complex linear closures OR reconstruction after skin cancer resection performed in the office-based setting where anticoagulant therapy was continued prior to surgery.\n\nThis measure is stratified by intermediate layer or complex linear closures AND reconstructive procedures.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™, ASPS TOPS-QCDR, MohsAIQ",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4649789",
      "8365868",
      "6621356",
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "resection",
        "description": "Strata 1: Intermediate layer or complex linear closures after skin cancer resection"
      },
      {
        "name": "reconstruction",
        "description": "Strata 2: Reconstruction after skin cancer resection"
      },
      {
        "name": "overall",
        "description": "Strata 3: FOR REPORTING"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS29",
    "title": "Avoidance of Opioid Prescriptions for Closure and Reconstruction After Skin Cancer Resection",
    "description": "Percentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, who had intermediate layer and/or complex linear closures OR reconstruction after skin cancer resection where opioid/narcotic therapy* was prescribed as first line therapy (as defined by a prescription in anticipation of or at time of surgery) for post-operative pain management by the reconstructing surgeon. (Inverse measure)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "AAD’s DataDerm™, ASPS TOPS-QCDR, MohsAIQ",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4649789",
      "8365868",
      "6621356",
      "6859936"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "resection",
        "description": "Strata 1: Intermediate layer or complex linear closures after skin cancer resection"
      },
      {
        "name": "reconstruction",
        "description": "Strata 2: Reconstruction after skin cancer resection"
      },
      {
        "name": "overall",
        "description": "Strata 3: FOR REPORTING"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ASPS5",
    "title": "Breast Reconstruction: Return to OR",
    "description": "Percentage of female patients aged 18 years and older who had breast reconstruction who have an unplanned second operation on the reconstruction site within 60 days of the primary breast reconstruction procedure.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "ASPS TOPS-QCDR",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "6621356"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP22",
    "title": "Turnaround Time (TAT) - Biopsies",
    "description": "Percentage of final pathology reports for biopsies that meet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 2 business days).\nINSTRUCTIONS: This measure is to be reported each time a biopsy is performed during the performance period. It is anticipated that eligible clinicians providing the pathology services for procedures will submit this measure.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP28",
    "title": "Helicobacter pylori Status and Turnaround Time",
    "description": "Percentage of stomach biopsy cases with gastritis that address the presence or absence of Helicobacter pylori \nAND\nmeet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 2 business days).\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases in which presence or absence of Helicobacter pylori is addressed.\n2. Percent of cases that meet the maximum 2 business day turnaround time.\nThe overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP30",
    "title": "Urinary Bladder Biopsy Diagnostic Requirements For Appropriate Patient Management",
    "description": "Percentage of urinary bladder carcinoma pathology reports that include the procedure, histologic tumor grade, histologic type, muscularis propria presence, presence/absence of lymphovascular invasion and extent of tumor invasion. \nAND \nmeet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 2 business days). \n\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1.\tPercent of cases for which all required data elements of the urinary bladder carcinoma pathology report are included.\n2.\tPercent of cases that meet the maximum 2 business day turnaround time.\nThe overall performance score submitted is a weighted average of: \n(Performance rate 1 x 70%)+(Performance rate 2 x 30%)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP32",
    "title": "Prostate Cancer Gleason Pattern, Score, and Grade Group",
    "description": "Percentage of surgical pathology reports for biopsies or radical resections (radical prostatectomy) of primary prostate cancer that include Gleason patterns used in determining the Gleason score, total Gleason score, and grade group classification",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP33",
    "title": "Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma",
    "description": "Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP34",
    "title": "Biomarker Status to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer",
    "description": "Percentage of non-small cell lung cancer (NSCLC) surgical pathology reports that include anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR), AND tyrosine protein kinase ROS1 mutation status.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP35",
    "title": "Cancer Protocol and Turnaround Time for Gastrointestinal Carcinomas: Gastric, Esophageal, Colorectal and Hepatocellular Carcinomas",
    "description": "Percentage of all eligible pathology reports for gastric, esophageal, colorectal, and hepatocellular carcinoma specimens for which all required data elements of the gastrointestinal Cancer Protocols are recorded \nAND \nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 4 business days). \n\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1.\tPercent of cases for which required data elements for all cancer protocols are recorded.\n2.\tPercent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: \n(Performance rate 1 x 70%)+(Performance rate 2 x 30%)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP36",
    "title": "p16 Immunohistochemistry Reporting for Human Papillomavirus in Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)",
    "description": "Percentage of surgical pathology reports for invasive oropharyngeal squamous cell carcinoma (OPSCC) with quantitative p16 immunohistochemistry (IHC) using a ≥70% nuclear and cytoplasmic staining cutoff performed as a surrogate for HR-HPV status",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CAP37",
    "title": "Cancer Protocol and Turnaround Time for Gynecologic and Genitourinary Carcinomas: Carcinoma of the Endometrium, Prostate, and Renal Tubular Origin",
    "description": "Percentage of all eligible pathology reports for specimens of carcinoma of the endometrium, prostate and renal tubular origin in which the required data elements of the gynecologic and genitourinary Cancer Protocols are recorded \nAND \nmeet the maximum 4 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 4 business days). \n \nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\n1.\tPercent of cases for which specified data elements for all cancer protocols are recorded.\n2.\tPercent of cases that meet the maximum 4 business day turnaround time.\nThe overall performance score submitted is a weighted average of: \n(Performance rate 1 x 70%)+(Performance rate 2 x 30%)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Pathologists Quality Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5688621"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CCOME1",
    "title": "Patient-Reported Pain and/or Function Improvement after Total Knee Arthroplasty",
    "description": "Percentage of patients 18 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "QI FORCE, OME",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "1157686",
      "6394618",
      "2217612",
      "1546118"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CCOME4",
    "title": "Patient-Reported Pain and/or Function Improvement after ACLR Surgery",
    "description": "Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "OME",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "1157686",
      "2217612"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CCOME5",
    "title": "Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy",
    "description": "Percentage of patients aged 45 and higher undergoing primary arthroscopic partial meniscectomy (APM) surgery who do not have grade IV chondromalacia in more than one compartment. On a per-surgeon level, the measure is expected to be 70% or higher; on a system level, the measure is expected to be 80% or higher.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "OME",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "1157686",
      "2217612"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CCOME6",
    "title": "Patient-Reported Pain and/or Function Improvement after APM Surgery",
    "description": "Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary arthroscopic partial meniscectomy (APM) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "OME",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "1157686",
      "2217612"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CCOME7",
    "title": "Patient-Reported Pain and/or Function Improvement after Total Hip Arthroplasty",
    "description": "Percentage of patients 18 years of age and older who obtained an improvement of at least 1 minimal clinically important difference (MCID) in hip pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total hip arthroplasty (THA) surgery. PROMs include any validated measures of hip-related pain and/or function with MCID thresholds supported by literature, including HOOS-Pain (24 points), HOOS-PS (23 points), and HOOS-JR (18 points).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "QI FORCE, OME",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "1157686",
      "6394618",
      "2217612",
      "1546118"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CCOME8",
    "title": "Patient-Reported Pain and/or Function Improvement after Total Shoulder Arthroplasty",
    "description": "Percentage of patients 18 years of age and older who obtained an improvement of at least 1 minimal clinically important difference (MCIDO) in shoulder pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total shoulder arthroplasty (TSA) surgery. PROMs include any validated measures of shoulder-related pain and/or function with MCID thresholds supported by literature, including PSS (11.4 points) and ASES (13.6 points).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "OME",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "1157686",
      "2217612"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR1",
    "title": "Adequate Off-loading of Diabetic Foot Ulcer at each visit",
    "description": "Percentage of visits in which diabetic foot ulcers among patients aged 18 years and received adequate off-loading during a 12-month reporting period, stratified by location of the ulcer.\n\nThe location of the diabetic foot ulcer on the foot (e.g. heel/midfoot vs. toes) determines the type of off-loading device that is appropriate, the patient's risk of falling, the probability of successful off-loading and thus the likelihood of major amputation. The clinician needs to assess the most appropriate off-loading option based on many different factors. \n\nThere are three rates reported for this measure.\nThe three rates will be risk stratified into two buckets (location of wound and/or ulcer) which are the following:\n1.\tMidfoot/heel\n2.\tToes\n3.\tThe average of the two risk stratified buckets which will be the performance rate in the XML submitted.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6621356",
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "midfoot/heel",
        "description": "Midfoot/heel"
      },
      {
        "name": "toes",
        "description": "Toes"
      },
      {
        "name": "overall",
        "description": "The average of the two risk stratified buckets which will be the performance rate in the JSON XML submitted."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR2",
    "title": "Diabetic Foot Ulcer (DFU) Healing or Closure",
    "description": "Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.\n\nThere are four rates reported for this measure.\nThree of the rates will be risk stratified into three buckets (minimum-maximum) which are the following:\n1. 0.00 – 62.42\n2. 62.42 – 73.19\n3. 73.19 – 93.45\n4. The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "bucket1",
        "description": "0.00 - 62.42"
      },
      {
        "name": "bucket2",
        "description": "62.42 - 73.19"
      },
      {
        "name": "bucket3",
        "description": "73.19 - 93.45"
      },
      {
        "name": "overall",
        "description": "The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR5",
    "title": "Adequate Compression at each visit for Patients with VLUs",
    "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older in which adequate compression is provided within the 12-month reporting period. Compression method should be appropriate to documented arterial supply. \n\nThere are four rates reported for this measure.\nThe four rates will be risk stratified into three buckets which are the following:\n1.\tNormal arterial supply- No restrictions on type of compression\n2.\tCompression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.)\n3.\tCompression bandaging not usually recommended\n4.\tThe average of the three risk stratified buckets which will be the performance rate in the XML submitted.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "normal",
        "description": "Normal arterial supply- No restrictions on type of compression"
      },
      {
        "name": "considerations",
        "description": "Compression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.)"
      },
      {
        "name": "notrecommended",
        "description": "Compression bandaging not usually recommended"
      },
      {
        "name": "overall",
        "description": "The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR6",
    "title": "Venous Leg Ulcer (VLU) outcome measure: Healing or Closure",
    "description": "Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "bucket1",
        "description": "0.00-73.24"
      },
      {
        "name": "bucket2",
        "description": "73.24 - 80.26"
      },
      {
        "name": "bucket3",
        "description": "80.26 - 87.21"
      },
      {
        "name": "overall",
        "description": "The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CDR8",
    "title": "Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcers",
    "description": "Percentage of patient with a diagnosis of a diabetic foot ulcer graded stage 3 or higher on the Wagner Grading System for Diabetic Foot Infections that received hyperbaric oxygen therapy (HBOT) appropriately.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CESQIP1",
    "title": "Post operative hypocalcemia after thyroidectomy surgery",
    "description": "The number or percent of patients with low calcium levels or negligible parathyroid hormone values reported at 30 days or more post op",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) of the Endocrine Quality Foundation, powered by ArborMetrix",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "9978062"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CESQIP3",
    "title": "Pre operative ultrasound exam of patients with thyroid cancer",
    "description": "Documentation of use and efficacy of complete pre op cervical ultrasound exam in cancer patients",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) of the Endocrine Quality Foundation, powered by ArborMetrix",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "9978062"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CESQIP5",
    "title": "Related readmission for adrenal related problems",
    "description": "Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: \n 1. Hematoma \n 2. Adrenal Insufficiency \n 3. Hypertension \n 4. Pain \n 5. Wound Infection \n 6. Pneumonia \n 7. Dehydration \n 8. Respiratory Distress",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) of the Endocrine Quality Foundation, powered by ArborMetrix",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "9978062"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "CESQIP9",
    "title": "qPTH >50% Reduction at End of Procedure",
    "description": "The percentage of patients where intra-operative PTH decreased by at least 50% from baseline",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) of the Endocrine Quality Foundation, powered by ArborMetrix",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "9978062"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR39",
    "title": "Avoid Head CT for Patients with Uncomplicated Syncope",
    "description": "Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825",
      "1718371",
      "4757099",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR40",
    "title": "Initiation of the Initial Sepsis Bundle",
    "description": "Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825",
      "1718371",
      "4757099",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR41",
    "title": "Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure",
    "description": "Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5133825",
      "1718371",
      "4757099"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR46",
    "title": "Avoidance of Opiates for Low Back Pain or Migraines",
    "description": "Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "5133825",
      "1718371",
      "4757099",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR50",
    "title": "Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients",
    "description": "Percentage of Urgent Care Patients Who Made Provider Contact Within 30 Minutes of Urgent Care Clinic (UCC) Arrival",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "5133825",
      "1718371"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR51",
    "title": "Discharge Prescription of Naloxone after Opioid Poisoning or Overdose",
    "description": "Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5133825",
      "1718371",
      "4757099",
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR52",
    "title": "Appropriate Treatment of Psychosis and Agitation in the Emergency Department",
    "description": "Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5133825",
      "1718371",
      "4757099"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR53",
    "title": "Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor Vehicles",
    "description": "Percentage of Patients At Risk for Recurrent Loss of Consciousness For Whom Loss of Consciousness Information Was Submitted to Department of Public Health or Department of Motor Vehicles",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5133825",
      "1718371"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR54",
    "title": "Avoidance of Co-Prescribing of Opioid Analgesic and Benzodiazepine",
    "description": "Percentage of Patients Who Were Not Concurrently Prescribed Opioid Analgesic and Benzodiazepine Medications",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "1718371",
      "4757099",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR55",
    "title": "Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain",
    "description": "Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5133825",
      "1718371",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ECPR56",
    "title": "Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment",
    "description": "Percentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication-Assisted Treatment and Referred to Outpatient Opioid Treatment",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "E-CPR (Emergency - Clinical Performance Registry), H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "1718371",
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP30",
    "title": "Ultrasound Guidance for Peripheral Nerve Block with Patient Experience",
    "description": "Percentage of patients, aged 18 years and older, who undergo upper or lower extremity peripheral nerve blockade and for whom ultrasound guidance is used and documented in the medical record and the patient is sent a survey within 30 days and the survey indicates experience with nerve block.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Anesthesia Quality Registry (AQR QCDR)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6775913",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "EPREOP31",
    "title": "Intraoperative Hypotension among Non-Emergent Noncardiac Surgical Cases",
    "description": "Percentage of general anesthesia cases in which mean arterial pressure (MAP) fell below 65 mmHg for cumulative total of 15 minutes or more",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Anesthesia Quality Registry (AQR QCDR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "6169123",
      "6775913",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FORCE21",
    "title": "Review of Pain Status Assessment for Patients with Osteoarthritis",
    "description": "Percentage of patients 18 years of age and older with osteoarthritis who completed baseline and follow-up patient-reported pain status assessment and reviewed the results of this assessment with their care provider.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "QI FORCE",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "2581402",
      "1546118"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FOTO2",
    "title": "Functional Status Change for Patients Post Stroke: Lower Body",
    "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ who have experienced a stroke with sequelae impacting functional abilities related to use of the foot, leg, and lower trunk. The change in FS is assessed using the Stroke Lower Extremity (SLE) FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient level, individual clinician level, and clinic level to assess quality. Free public access is available at https://www.fotoinc.com/science-of-foto/nqf-measure-specifications.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "FOTO QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8311170"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FOTO3",
    "title": "Functional Status Change for Patients Post Stroke: Upper Body",
    "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ who have experienced a stroke with sequelae impacting functional abilities related to use of the hand, arm, and upper trunk. The change in FS is assessed using the Stroke Upper Extremity (SUE) FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient level, individual clinician level, and clinic level to assess quality. Free public access is available at https://www.fotoinc.com/science-of-foto/nqf-measure-specifications.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "FOTO QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8311170"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "FOTO4",
    "title": "Functional Status Changes for Patients with Upper or Lower Extremity Regional Swelling",
    "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ with lymphedema or other causes of regional swelling. For patients with such conditions affecting the leg, foot, groin, or lower trunk regions, the change in FS is assessed using the FOTO Lower Extremity Regional Swelling (LERS) FS PROM. For patients with such conditions affecting the arm, hand, chest, or breast body regions, the change in FS is assessed using the FOTO Upper Extremity Regional Swelling (UERS) FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient level, individual clinician level, and clinic level to assess quality. Free public access is available at https://www.fotoinc.com/science-of-foto/nqf-measure-specifications.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "FOTO QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8311170"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "GIQIC10",
    "title": "Appropriate management of anticoagulation in the peri-procedural period rate – EGD",
    "description": "Percentage of patients undergoing an EGD on an anti-platelet agent or an anticoagulant who leave the endoscopy unit with instructions for management of this medication",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "GIQuIC",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "5846856"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "GIQIC22",
    "title": "Screening Colonoscopy Adenoma Detection Rate",
    "description": "The percentage of patients aged 50 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "GIQuIC",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5846856",
      "6981170"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "overall",
        "description": "Overall percentage of patients aged 50 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy"
      },
      {
        "name": "malePatients",
        "description": "Percentage of male patients aged 50 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy"
      },
      {
        "name": "femalePatients",
        "description": "Percentage of female patients aged 50 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "GIQIC23",
    "title": "Appropriate follow-up interval based on pathology findings in screening colonoscopy",
    "description": "Percentage of procedures among average-risk patients aged 50 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "GIQuIC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "5846856",
      "6981170"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "overall",
        "description": "Overall percentage of procedures among average-risk patients aged 50 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report"
      },
      {
        "name": "biopsy&FollowUp",
        "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 50 to 75 years with biopsy or polypectomy and pathology findings of only hyperplastic polyps for which a recommended follow-up interval of 10 years for repeat colonoscopy was given to the patient"
      },
      {
        "name": "hyperPolyps&FollowUp",
        "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 50 to 75 years with biopsy or polypectomy and pathology findings of 1-2 tubular adenoma(s) for which a recommended follow-up interval of not less than 7 years and not greater than 10 years was given to the patient"
      },
      {
        "name": "1-2adenoma&FollowUp",
        "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 50 to 75 years with biopsy or polypectomy and pathology findings of 3-4 tubular adenomas for which a recommended follow-up interval of not less than 3 years and not greater than 5 years was given to the patient"
      },
      {
        "name": "3-4adenomas&FollowUp",
        "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 50 to 75 years with biopsy or polypectomy and pathology findings of 5-10 tubular adenomas for which a recommended follow-up interval of 3 years was given to the patient"
      },
      {
        "name": "5-10adenoma&FollowUp",
        "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 50 to 75 years with biopsy or polypectomy and pathology findings of Advanced Neoplasm (≥ 10 mm, high grade dysplasia, villous component) for which a recommended follow-up interval of 3 years for repeat colonoscopy was given to the patient"
      },
      {
        "name": "neoplasm&FollowUp",
        "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 50 to 75 years with biopsy or polypectomy and pathology findings of Sessile serrated polyp ≥ 10 mm OR sessile serrated polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy consistent was given to the patient"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR14",
    "title": "Venous Thromboembolism (VTE) Prophylaxis",
    "description": "Percentage of Adult Patients Who Had VTE Prophylaxis Ordered at the Time of Admission OR Have Documentation of Reason for No VTE Prophylaxis",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "4757099",
      "8483899",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR16",
    "title": "Physician’s Orders for Life-Sustaining Treatment (POLST) Form",
    "description": "Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "4757099",
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR17",
    "title": "Pressure Ulcers – Risk Assessment and Plan of Care",
    "description": "Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "4757099",
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR18",
    "title": "Unintentional Weight Loss – Risk Assessment and Plan of Care",
    "description": "Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "4757099",
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR20",
    "title": "Clostridium Difficile – Risk Assessment and Plan of Care",
    "description": "Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "4757099",
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR22",
    "title": "Critical Care Transfer of Care – Use of Verbal Checklist or Protocol",
    "description": "Percentage of Adult Patients Transferred from the Critical Care Service to a Non-critical Care Service Who Had Documented Use of a Verbal Protocol for the Transfer of Care Between the Transferring Clinician and the Accepting Clinician",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8483899",
      "1725296"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HCPR23",
    "title": "Avoidance of Echocardiogram and Carotid Ultrasound for Syncope",
    "description": "Percentage of Patients Presenting with Syncope Who Did Not Have an Echocardiogram or Carotid Ultrasound Ordered",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "8483899"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM10",
    "title": "Outcomes of Hearing Loss Treatment",
    "description": "Percentage of patients aged 50 years and older, who are screened with a hearing loss self-assessment tool that indicated an impact on hearing-related QoL AND if diagnosed with a mild or greater hearing loss in at least one ear or identified with a hearing loss, receive an audiologic care plan and hearing loss intervention(s) AND report a meaningful clinically important difference (MCID) improvement in hearing-related quality of life (QoL) within 12 months of hearing loss diagnosis.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "qolSelfAssessment",
        "description": "Percentage of patients aged 50 years and older evaluated for hearing loss, who are screened to determine if the hearing loss is impacting their QoL with a self-assessment measure."
      },
      {
        "name": "qolPlan&Intervention",
        "description": "Percentage of patients aged 50 years and older diagnosed with a mild or greater hearing loss in at least one ear or identified with a hearing loss that impacts their hearing-related QoL who receive an audiologic care plan AND hearing loss intervention(s)."
      },
      {
        "name": "overall",
        "description": "Percentage of patients who report a MCID improvement in hearing-related quality of life (QoL) within 12 months of hearing loss diagnosis if they received an audiologic care plan AND hearing loss intervention(s )."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM11",
    "title": "Outcomes of Treatment of Subjective Tinnitus",
    "description": "Percentage of patients aged 18 years and older who are screened for bothersome subjective tinnitus AND, if patient reports symptoms, assessed with clinical evaluation for tinnitus severity and impact on hearing-related quality of life (HRQoL) using a validated self-assessment tool AND, if identified with tinnitus that impacts the patients HRQoL, receive a tinnitus-related care plan, and tinnitus-related intervention(s), treatment(s), or management AND who report a meaningful clinically important difference (MCID) improvement in the impact of tinnitus on the patient’s HRQoL within 12 months of initial identification.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "tinnitusScreen",
        "description": "Percentage of patients aged 18 years and older who are screened for presence of bothersome subjective tinnitus"
      },
      {
        "name": "screenReferOrAssess",
        "description": "Percentage of patients aged 18 years and older reporting bothersome tinnitus symptoms AND referred for further investigation OR assessed with clinical evaluation for tinnitus severity and a validated self-assessment tool (THI, TRQ, TFI) to determine the impact of tinnitus on their HRQoL."
      },
      {
        "name": "qolPlan&Intervention",
        "description": "Percentage of patients aged 18 years and older reporting bothersome tinnitus that is impacting their HRQoL who receive a tinnitus-related care plan AND tinnitus-related intervention(s), treatment(s), or management"
      },
      {
        "name": "overall",
        "description": "Percentage of patients aged 18 years and older identified with bothersome tinnitus that is impacting their HRQoL who have received a tinnitus-related care plan, and tinnitus-related intervention(s), treatment(s), or management AND who report a MCID improvement in the impact of tinnitus on the HRQoL within 12 months of initial identification."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM12",
    "title": "Outcomes of Treatment of Benign Paroxysmal Positional Vertigo",
    "description": "Percentage of patients aged 18 years and older, who report benign paroxysmal positional vertigo (BPPV)-related symptoms and are screened with a dizziness assessment questionnaire and undergo positional nystagmus testing AND, if diagnosed or identified with BPPV, received a BPPV-related care plan and vestibular intervention(s) or treatment(s) AND who have an improvement in nystagmus or report an improvement in BPPV-related symptoms, and report a meaningful clinically important difference (MCID) improvement of BPPV-related quality of life (QoL).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "bppvScreen",
        "description": "Percentage of patients aged 18 years and older, who report BPPV-related symptoms and who are screened with a dizziness assessment questionnaire, undergo positional nystagmus testing, and are referred, identified or diagnosed BPPV."
      },
      {
        "name": "bppv&Plan",
        "description": "Percentage of patients who are screened with a dizziness assessment questionnaire, undergo positional nystagmus testing, and are diagnosed or identified with BPPV who received a BPPV-related care plan on the date the BPPV was identified or diagnosed and received vestibular intervention(s) or treatment(s) within 30 days of the documented BPPV-related care plan."
      },
      {
        "name": "overall",
        "description": "Percentage of patients who received a BPPV-related care plan, and vestibular intervention(s) or treatment(s) , AND who have an improvement in nystagmus OR report an improvement in BPPV-related symptoms, AND report a MCID improvement of BPPV-related QoL."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM4",
    "title": "Functional Status Change for Patients With Upper-limb Functional Status Deficit",
    "description": "Percentage of patients aged 13 years or older with a functional deficit related to the upper-limb who achieve a Minimal Clinically Important Difference (MCID) in QuickDASH or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported:\n•\tThe overall proportion of patients achieving an MCID in QuickDASH change score.\n•\tThe Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via QuickDASH or equivalent tool) proportion is greater than zero.\n\nThe measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM5",
    "title": "Functional Status Change for Patients With Neck Functional Status Deficit",
    "description": "Percentage of patients aged 18 years or older with a functional deficit related to the neck who achieve a Minimal Clinically Important Difference (MCID) in the Neck Disability Index (NDI) or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported:\n•\tThe overall proportion of patients achieving an MCID in NDI change score.\n•\tThe Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via NDI or equivalent tool) proportion is greater than zero.\n\nThe measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "surgical",
        "description": "Submission Criteria 1: All patients Neck (surgical)"
      },
      {
        "name": "nonsurgical",
        "description": "Submission Criteria 2: All patients Neck (non-surgical)"
      },
      {
        "name": "overall",
        "description": "Submission Criteria 3: All patients Neck (surgical and non-surgical)"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM6",
    "title": "Functional Status Change for Patients With Low Back Functional Status Deficit",
    "description": "Percentage of patients aged 18 years or older with a functional deficit related to the low back who achieve a Minimal Clinically Important Difference (MCID) in the Modified Oswestry Low Back Pain Questionnaire (ODI) or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported:\n· The overall proportion of patients achieving an MCID in NDI change score.\n· The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via NDI or equivalent tool) proportion is greater than zero.\n \nThe measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "surgical",
        "description": "Submission Criteria 1: All patients (surgical)"
      },
      {
        "name": "nonsurgical",
        "description": "Submission Criteria 2: All patients (non-surgical)"
      },
      {
        "name": "overall",
        "description": "Submission Criteria 3: All patients (surgical and non-surgical)"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM7",
    "title": "Functional Status Change for Patients with Vestibular Dysfunction",
    "description": "Percentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) as measured via the validated Dizziness Handicap Inventory or equivalent instrument to indicate functional, emotional, and physical improvement \n·        Submission Age Criteria 1: Patients aged 14-17 years of age \n·        Submission Age Criteria 2: Patients aged 18-64 years of age\n·        Submission Age Criteria 3: Patients aged 65 years and older\n·        Submission Criteria 4: Overall total rate of patients aged 14 years and older \nThe measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "14to17",
        "description": "SUBMISSION CRITERIA 1: Patients aged 14-17 years of age on date of encounter"
      },
      {
        "name": "18to64",
        "description": "SUBMISSION CRITERIA 2: Patients aged 18-64 years and older on date of encounter"
      },
      {
        "name": "65over",
        "description": "SUBMISSION CRITERIA 3: Patients aged 65 years of age and older on date of encounter"
      },
      {
        "name": "overall",
        "description": "SUBMISSION CRITERIA 4: Patients aged 14 years of age and older on date of encounter"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM8",
    "title": "Functional Status Change for Patients With Lower Extremity Functional Status Deficit",
    "description": "Percentage of patients aged 18 years or older with a functional deficit related to the lower extremity who achieve a Minimal Clinically Important Difference (MCID) in Lower Extremity Functional Scale (LEFS) score that indicates a functional improvement greater than zero. Two rates will be reported:\n•\tThe overall proportion of patients achieving an MCID in LEFS change score.\n•\tThe Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via LEFS) proportion is greater than zero.\n\nThe measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "ft-s",
        "description": "SUBMISSION CRITERIA 1: Foot and Ankle operative (surgical) patients"
      },
      {
        "name": "ft-ns",
        "description": "SUBMISSION CRITERIA 2: Foot and Ankle (non-surgical) patients"
      },
      {
        "name": "k-s",
        "description": "SUBMISSION CRITERIA 3: Knee operative (surgical) patients"
      },
      {
        "name": "k-ns",
        "description": "SUBMISSION CRITERIA 4: Knee (non-surgical) patients"
      },
      {
        "name": "hp-s",
        "description": "SUBMISSION CRITERIA 5: Hip and Pelvis operative (surgical) patients"
      },
      {
        "name": "hp-ns",
        "description": "SUBMISSION CRITERIA 6: Hip and Pelvis (non-surgical) patients"
      },
      {
        "name": "fakhp-s",
        "description": "SUBMISSION CRITERIA 7: Foot, Ankle, Knee, Hip and Pelvis (surgical) patients"
      },
      {
        "name": "fakhp-ns",
        "description": "SUBMISSION CRITERIA 8: Foot, Ankle, Knee, Hip and Pelvis (non-surgical) patients"
      },
      {
        "name": "overall",
        "description": "SUBMISSION CRITERIA 9: Foot, Ankle, Knee, Hip and Pelvis (surgical and non-surgical patients)"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "HM9",
    "title": "Functional Benefit of a Cochlear Implant",
    "description": "Percentage of patients aged 18 years and older, who are evaluated for hearing loss and complete a hearing loss self-assessment tool that indicated an impact of hearing-related quality of life (QoL), and if diagnosed with a bilateral moderate to profound sensorineural hearing loss (SNHL) and less than 60% open set speech recognition are scheduled or referred for cochlear implant candidacy testing AND for patients who undergo cochlear implantation, demonstrate a meaningful clinically important difference (MCID) improvement in self-assessment of Hearing-related QoL or an improvement in speech recognition within 18 months of cochlear implant activation.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MIPSPRO ENTERPRISE",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "snhl&scheduleOrRefer",
        "description": "Percentage of patients aged 18 years and older, who are evaluated for hearing loss and who indicate, via a hearing self-assessment tool, that the hearing loss is impacting their hearing-related QoL, and if diagnosed with a bilateral moderate to profound SNHL and less than 60% open set speech recognition are scheduled or referred for cochlear implant candidacy testing."
      },
      {
        "name": "overall",
        "description": "Percentage of patients aged 18 years and older, who are evaluated for hearing loss and who indicate, via a hearing self-assessment tool, that the hearing loss is impacting their hearing-related QoL, and if Percentage of patients aged 18 years or older evaluated for hearing loss who complete a hearing self-assessment tool that indicated an impact of hearing QoL, and if diagnosed with a bilateral moderate to profound SNHL and less than 60% open set speech recognition are scheduled or referred for cochlear implant candidacy testing AND demonstrate a MCID improvement in self-assessment of HRQoL or an improvement in speech recognition within 18 months of cochlear implant activation."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR1",
    "title": "Comprehensive TTE studies reporting a measured value of LVEF AND wall motion findings with LVEF < 50%",
    "description": "Percentage of comprehensive TTE studies reporting a measured value of LVEF and wall motion findings with LVEF < 50% on patients 18 years of age or older.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR10",
    "title": "Transthoracic Echo (TTE) performance per ASE guidelines",
    "description": "Transthoracic Echo (TTE) performance per ASE guidelines on patients 18 years of age or older. This is a multi-strata measure consisting of the following:\n1. Percentage of comprehensive TTE studies reporting 100% obtainment of required views.\n2. Percentage of limited and comprehensive TTE studies where the study quality was poor or technically difficult that utilized contrast.\n3. Percentage of comprehensive TTE studies reporting pulmonary artery pressures.\n4. Percentage of comprehensive TTE studies reporting of diastolic function.\n5. Percentage of limited and comprehensive TTE studies reporting cardiac function using strain analysis in patients receiving chemotherapy.\nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR12",
    "title": "Appropriate diagnosis verification and severity grading for valve disease through transthoracic echocardiography (TTE) quantitative parameters.",
    "description": "This measure addresses changes in cardiac structure and function in patients with aortic stenosis and/or mitral regurgitation. Changes in left ventricular size and function AND quantitative assessment of severity of aortic stenosis and/or mitral regurgitation should be performed in patients with significant left sided valvular lesions. Both sets of data (left ventricle structure and function, and extent of valvular disease) are needed to reach a conclusion about whether valve surgery or repair is needed. While qualitative assessments are commonly employed, they are generally inadequate to determine severity and to track changes over time.\n\nThis is a multi-strata measure consisting of the following strata: \n1. Percentage of transthoracic echocardiogram reports with at least moderate mitral regurgitation including qualitative MR severity, two quantitative MR measurements to support the qualitative severity grading, quantitative LVEF, one quantitative measurement of LV size at end diastole and end systole, AND blood pressure at time of study. \n2. Percentage of transthoracic echocardiogram reports with at least moderate aortic stenosis including peak velocity, mean systolic gradient, aortic valve area, quantitative LVEF, one quantitative measurement of LV size at end diastole and end systole, AND blood pressure at the time of study\n\nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR14",
    "title": "Appropriate Evaluation of Left Ventricular Structure and Systolic Function with Transthoracic Echocardiography (TTE) to Guide Heart Failure and Cardiomyopathy Management",
    "description": "This measure addresses appropriate evaluation of left ventricular structure and systolic function with TTE to guide heart failure and cardiomyopathy management on patients 18 years of age or older. It examines percentage (%) of comprehensive transthoracic echocardiogram (TTE) studies performed on patients with heart failure/cardiomyopathy as the reason for the study, and including the following parameters for the study: \n - LV end-diastolic and end systolic diameters, end diastolic LV interventricular septum thickness and LV posterior wall thickness measurements \n - LV mass index calculation \n - Strain technology utilization\n - Use of intravenous contrast agent to visualize endocardial borders for LV volumes and ejection fraction (EF) measurement in technically difficult studies.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR15",
    "title": "Myocardial Perfusion Imaging (MPI) or Stress Echocardiography Imaging Studies - Adequate Exercise Protocol",
    "description": "This is a multi-strata measure consisting of the following strata: \n1. Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography studies using a Stress Test Type that includes exercise performed on patients 18 years of age or older.\n2 .Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography exercise studies where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise performed on patients 18 years of age or older.\n\nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "exerciseAsStressor",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography studies using a Stress Test Type that includes exercise performed on patients 18 years of age or older."
      },
      {
        "name": "hrAndMinExercised",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography exercise studies where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise performed on patients 18 years of age or older."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR16",
    "title": "Myocardial Perfusion Imaging (MPI) Studies, Transthoracic Echo (TTE), or Stress Echocardiography Imaging Studies - Adequate Reporting for Appropriate Interventions",
    "description": "This is a multi-strata measure consisting of the following strata: \n1. Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies that were abnormal and contained perfusion defects documentation including location, severity, and size performed on patients 18 years of age or older.\n2. Percentage of Single Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI), transthoracic echocardiography, or stress echocardiography imaging studies where the Left Ventricle Ejection Fraction (LVEF) was calculated and included in the report performed on patients 18 years of age or older.\n\nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "perfusionDefects",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies that were abnormal and contained perfusion defects documentation including location, severity, and size performed on patients 18 years of age or older."
      },
      {
        "name": "lvefDocumented",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI), transthoracic echocardiography, or stress echocardiography imaging studies where the Left Ventricle Ejection Fraction (LVEF) was calculated and included in the report performed on patients 18 years of age or older."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR17",
    "title": "Myocardial Perfusion Imaging (MPI) studies - Radiation Reduction Strategies",
    "description": "This is a multi-strata measure consisting of the following strata: \n1. Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the imaging protocol used was stress only performed on patients 18 years of age or older.\n2. Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies where 9 or less millisieverts of radiation were administered per ASNC guideline recommendations on patients 18 years of age or older.\n\nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "stressOnlyProtocol",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the imaging protocol used was stress only performed on patients 18 years of age or older."
      },
      {
        "name": "9OrLessMillisieverts",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies where 9 or less millisieverts of radiation were administered per ASNC guideline recommendations on patients 18 years of age or older."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR18",
    "title": "Myocardial Perfusion Imaging (MPI) or Stress Echocardiography imaging studies - Improving Image Quality",
    "description": "This is a multi-strata measure consisting of the following strata: \n1. Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction performed on patients 18 years of age or older.\n2.Percentage of SPECT-MPI or Stress Echocardiography imaging studies where the Imaging Protocol was appropriate for morbidly obese patients 18 years of age or older.\n\nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "attentuationCorrectn",
        "description": "Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction performed on patients 18 years of age or older."
      },
      {
        "name": "obesityProtocol",
        "description": "Percentage of SPECT-MPI or Stress Echocardiography imaging studies where the Imaging Protocol was appropriate for morbidly obese patients on patients 18 years of age or older."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR2",
    "title": "Parameters in stress echocardiography dobutamine testing for low flow, low gradient aortic stenosis",
    "description": "Percentage of low flow, low gradient aortic stenosis studies in the setting of LVEF < 50% with complete measurements during a dobutamine stress echocardiogram on patients 18 years of age or older.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IGR9",
    "title": "Stress echo performance for shortness of breath per ASE guidelines",
    "description": "Stress echo performance for shortness of breath per ASE guidelines on patients 18 years of age or older. This is a multi-strata measure consisting of the following: \n1. Percentage of stress echo studies presenting with an indication of unexplained dyspnea that include an interpretation of LV diastolic function parameters with exercise.\n2. Percentage of stress echo studies presenting with significant aortic or mitral valve disease that include reporting of value function and regurgitation with exercise. \nThe overall performance will be calculated using a weighted average.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "ImageGuide Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6034942"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS1",
    "title": "Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better",
    "description": "Percentage of endothelial keratoplasty patients with a best corrected visual acuity of 20/40 or better within 90 days after surgery",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS13",
    "title": "Diabetic Macular Edema - Loss of Visual Acuity",
    "description": "Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) within the past 12 months.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS17",
    "title": "Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells",
    "description": "Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS2",
    "title": "Glaucoma – Intraocular Pressure Reduction",
    "description": "Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IRIS23",
    "title": "Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days",
    "description": "Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better within 30 days",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS24",
    "title": "Refractive Surgery: Patients with a postoperative correction within + or - 0.5 Diopter (D) of the intended correction",
    "description": "Percentage of patients with an actual spherical equivalent within + or - 0.5 D of the intended correction or SE",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS26",
    "title": "Avoidance of Routine Antibiotic Use in Patients Before or After Intravitreal Injections",
    "description": "The percentage of patients, aged 18 years and older, who received topical or systemic antibiotics before or after intravitreal injections",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS35",
    "title": "Improvement of Macular Edema in Patients with Uveitis",
    "description": "Percentage of patients with uveitis and macular edema with a reduction of 20% or greater in the central subfield thickness on OCT within 90 days after treatment.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS38",
    "title": "Endothelial Keratoplasty – Dislocation Requiring Surgical Intervention",
    "description": "Percentage of endothelial keratoplasty patients with a rebubbling or revision or repair procedure within 90 days after surgery",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS39",
    "title": "Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure",
    "description": "Percentage of patients who underwent trabeculectomy or aqueous shunt procedure who had IOP reduced by 20% or more from their pretreatment between 3 and 4 months of treatment or a reduction in overall number of glaucoma medications.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS41",
    "title": "Improved visual acuity after epiretinal membrane treatment within 120 days",
    "description": "Percentage of patients with a 20% improvement in visual acuity within 120 days following epiretinal membrane treatment",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
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    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS43",
    "title": "Intraocular Pressure Reduction Following Laser Trabeculoplasty",
    "description": "Percentage of patients who underwent laser trabeculoplasty who had IOP reduced by 20% or more from their pretreatment IOP or had a reduction in overall number of glaucoma medications.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS44",
    "title": "Visual Field Progression in Glaucoma",
    "description": "Percentage of patients with a diagnosis of glaucoma with a mean deviation loss of 3dB or more from their baseline value.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS45",
    "title": "Exudative Age-Related Macular Degeneration: Loss of Visual Acuity",
    "description": "Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) of visual acuity within the past 12 months. First performance rate used for reporting.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS46",
    "title": "Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT",
    "description": "Percentage of patients with a macular hole who have evidence of anatomic closure documented by OCT within 90 days after surgical treatment.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS48",
    "title": "Adult Surgical Esotropia: Postoperative alignment",
    "description": "Percentage of adult esotropia patients receiving surgical treatment with a post treatment alignment of 12 prism diopters (PD) or less.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS49",
    "title": "Surgical Pediatric Esotropia: Postoperative alignment",
    "description": "Percentage of surgical esotropia pediatric patients with a postoperative alignment of 12 prism diopters (PD) or less without a reoperation.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS5",
    "title": "Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD)",
    "description": "Percentage of surgical ptosis patients with an improvement of MRD within 90 days postoperatively.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS50",
    "title": "Amblyopia: Interocular visual acuity",
    "description": "Percentage of newly diagnosed amblyopic patients with one or more of the following:\nA. a corrected interocular (or if not reported, the uncorrected) visual acuity difference < 0.23 logMAR 3-12 months after first diagnosis of amblyopia\nOR\nB. an improvement in the corrected visual acuity of the amblyopic eye of 3 or more Snellen lines (> or = 0.30 logMAR) 3-12 months after first diagnosis of amblyopia \nOR\nC. a final visual acuity in the amblyopic eye equal to 20/30 or better (less than or equal to 0.18 logMar) 3-12 months after first diagnosis of amblyopia",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS51",
    "title": "Acute Anterior Uveitis: Post-treatment visual acuity",
    "description": "Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/20 or better or patients whose visual acuity had returned to their baseline value prior to onset of uveitis.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS52",
    "title": "Post-operative opioid management following ocular surgery",
    "description": "Percentage of patients aged 18 years and older who underwent ocular surgical procedures who were assessed for opioid use/requirements post-operatively, defined by either not receiving opioids post-operatively, receiving opioids for pain for 7 days or less post-operatively, or if expected to require opioids for more than 7 days after the surgical procedure, having an opioid use management plan documented.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS53",
    "title": "Chronic Anterior Uveitis - Post-treatment visual acuity",
    "description": "Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/30 or better or patients whose visual acuity had returned to their baseline value prior to onset of uveitis.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS54",
    "title": "Complications After Cataract Surgery",
    "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had the following complications with 90 days after cataract surgery: prolonged inflammation, incision complications, iris complications, retinal detachment, cystoid macular edema, corneal complications, or a return to OR.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS55",
    "title": "Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery",
    "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and minimally invasive glaucoma surgery and achieved 20/30 best-corrected distance visual acuity or better OR an improvement in best-corrected distance visual acuity within 4 months following the cataract surgery. Weighted average of performance rates reported.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "20/30+",
        "description": "Includes eyes of patients with mild to moderate stage glaucoma and a 20/30 or better post-operative best-corrected distance visual acuity"
      },
      {
        "name": "20/200",
        "description": "Includes eyes of patients with severe stage glaucoma or a pre-operative best-corrected visual acuity of 20/200 and a 2 lines or better improvement in the post-operative best-corrected distance visual acuity from preoperative visual acuity"
      },
      {
        "name": "20/400",
        "description": "Includes eyes of patients with a pre-operative best-corrected visual acuity of 20/400 and a 1 line or better improvement in the post-operative best-corrected distance visual acuity from pre-operative visual acuity"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS56",
    "title": "Adult Diplopia: Improvement of ocular deviation or absence of diplopia or functional improvement",
    "description": "Percentage of patients with a diagnosis of double vision (diplopia) who had an improvement of ocular deviation as determined by reduction of strabismus in primary gaze to <10 prism diopters horizontal or <2 prism diopters vertical deviation OR were absent of diplopia in primary gaze OR had functional improvement in ptosis within 6 months of initiating treatment.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS57",
    "title": "Idiopathic Intracranial Hypertension: Improvement of mean deviation or stability of mean deviation",
    "description": "Percentage of patients with improvement in mean deviation or stability of mean deviation (+1db) within 6 months of initiating therapy.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS58",
    "title": "Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days",
    "description": "Percentage of patients with a 20% or greater improvement in visual acuity within 120 days following vitrectomy for complications of diabetic retinopathy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
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    "allowedPrograms": [
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      "pcf"
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    "category": "quality",
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS59",
    "title": "Regaining Vision After Cataract Surgery",
    "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and 20/20 best-corrected distance visual acuity or better OR an improvement in best-corrected distance visual acuity within 30 days following the cataract surgery. Weighted average of performance rates reported.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "nocomorbidities",
        "description": "Includes eyes of patients with no comorbidities or additional procedures on the same date as the cataract surgery,"
      },
      {
        "name": "comorbidities&20/200",
        "description": "Includes eyes of patients with comorbidities with a pre-operative visual acuity of 20/200 or better, and"
      },
      {
        "name": "comorbidities&20/400",
        "description": "Includes eyes of patients with comorbidities with a pre-operative visual acuity of 20/400 or worse"
      }
    ],
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "IRIS6",
    "title": "Acquired Involutional Entropion: Normalized lid position after surgical repair",
    "description": "Percentage of surgical entropion patients with normalized lid position within 90 days postoperatively.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "3927141"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IRIS60",
    "title": "Visual Acuity Improvement Following Cataract Surgery Combined with a Trabeculectomy or an Aqueous Shunt Procedure",
    "description": "Percentage of eyes of patients who underwent cataract surgery combined with a trabeculectomy or an aqueous shunt procedure who had their visual acuity improve 1 or 2 or more Snellen lines from their preoperative visual acuity between 3 and 6 months postoperatively. Weighted average of performance rates reported.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "3927141"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "weightedAverage",
    "strata": [
      {
        "name": "better20/200",
        "description": "Includes eyes of patients with a pre-operative visual acuity of better than 20/200 who had an improvement from their preoperative visual acuity of 2 or more lines between 3 and 6 months postoperatively"
      },
      {
        "name": "20/200",
        "description": "Includes eyes of patients with a pre-operative visual acuity of 20/200 who had an improvement from their preoperative visual acuity of 2 or more lines between 3 and 6 months postoperatively"
      },
      {
        "name": "20/400",
        "description": "Includes eyes of patients with a pre-operative visual acuity of 20/400 who had an improvement from their preoperative visual acuity of 1 or more lines between 3 and 6 months postoperatively"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "IROMS11",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.",
    "description": "The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in KOS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in KOS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in KOS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via KOS) proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS12",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with knee injury pain.",
    "description": "The proportion of patients failing to achieve MCID of two (2) points or more improvement in the NPRS change score for patients with knee injuries treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS13",
    "title": "Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.",
    "description": "The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in LEFS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in LEFS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in LEFS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via LEFS) proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS14",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.",
    "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS15",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).",
    "description": "The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in NDI change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in NDI change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in NDI change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via NDI) proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS16",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.",
    "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS17",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.",
    "description": "The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in MDQ change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in MDQ change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in MDQ change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via MDQ) proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS18",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with low back pain.",
    "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS19",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.",
    "description": "The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted DASH change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).\n\nThese measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in DASH change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in DASH change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in DASH change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID (measured via DASH) proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "IROMS20",
    "title": "Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.",
    "description": "The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported. \n\nAdditionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). \n\nThese measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "Keet Outcomes",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "3967247",
      "1157686",
      "8411367",
      "2581402"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "notachieving",
        "description": "Overall proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "overall",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "operativeMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "operativeRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      },
      {
        "name": "nonOpMCID",
        "description": "The proportion of patients not achieving an MCID in the NPRS change score will be reported."
      },
      {
        "name": "nonOpRisk",
        "description": "A risk-adjusted MCID proportional difference will be reported where the difference between the risk model predicted and observed MCID proportion will reported."
      }
    ],
    "submissionMethods": [
      "registry"
    ],
    "benchmarks": {
      "registry": "removed"
    }
  },
  {
    "measureId": "MBHR1",
    "title": "Use of Anxiety Severity Measure",
    "description": "The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, BAI) during measurement period.",
    "nqfId": "n/a",
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR10",
    "title": "Symptom Improvement in adults with ADHD",
    "description": "The percentage of adult patients (18 years of age or older) with a diagnosis of ADHD who show a reduction in symptoms of 25% on the Adult ADHD Self-Report Scale (ASRS-v1.1)- 18 item self-report scale of ADHD symptoms within 2 to 10months after initially reporting significant symptoms. There are two aspects to this measure. The first is the assessment of the use of the ASRS v.1. during the denominator identification period (Criteria 1 also referred to as Time 1) and the second is the assessment of improvement in the ASRS v.1.1 from the first administration to the second administration of the ASRS v.1.1 (Criteria 2 also referred to as Time 2).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "screening",
        "description": "Documentation of a standardized tool to assess ADHD (i.e., ASRS checklist) and a document care of plan"
      },
      {
        "name": "overall",
        "description": "Patient demonstrated an ASRS score that is reduced by 25% or greater from the index score, 2-10 months after index date"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR11",
    "title": "Cognitive Assessment with Counseling on Safety and Potential Risk",
    "description": "Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) reporting of results included counseling on safety and potential risks.",
    "nqfId": "n/a",
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR12",
    "title": "Patient Feedback of Test Results Following Cognitive or Mental Status Assessment",
    "description": "Percentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback on test results directly to patient and/or their caregiver.",
    "nqfId": "n/a",
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR2",
    "title": "Anxiety Response at 6-months",
    "description": "The percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment at 6-months (+/- 60 days) after an index visit.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR3",
    "title": "Pain Interference Response utilizing PROMIS",
    "description": "The percentage of adult patients (18 years of age or older) who report chronic pain issues and demonstrated a response to treatment at one month from the index score",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4067715",
      "7037323"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR4",
    "title": "Social Role Functioning Outcome utilizing PROMIS",
    "description": "The percentage of adult patients (18 years of age or older) with a mood or anxiety disorder who report concerns related to their psychosocial function and demonstrated a response to treatment six months (+/- 120 days) after the index visit",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR5",
    "title": "Screening and monitoring for psychosocial problems among children and youth",
    "description": "Percentage of children from 3 to 17 years of age who are receiving a psychiatric or behavioral health intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 10 months after initial positive screen for externalizing and internalizing behavior problems.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "broadband",
        "description": "Patient administered a psychiatric screening to assess health broad-band psychosocial problem"
      },
      {
        "name": "overall",
        "description": "Patient administered a psychiatric or behavioral health intake visit with a positive PSC-ES/PSC-IS screening who demonstrated a reliable improvement of 2 or more points on parent-report version of the PSC-ES/PSC-IS assessment taken 2 to 10 months later"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR6",
    "title": "Sleep Quality Assessment and Sleep Response at 3-months",
    "description": "Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool AND demonstrated a response to treatment at three months (+/- 60 days) after index visit",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "reported",
        "description": "Documentation of a standardized tool to assess sleep quality and a document care of plan (e.g. Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI))"
      },
      {
        "name": "overall",
        "description": "Patient demonstrated an Insomnia Severity Index (ISI) that is reduced by 5 points or greater from the index Insomnia Severity Index (ISI) score, three months (+/- 60 days) after index date"
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR7",
    "title": "Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children",
    "description": "The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event AND with documentation of a standardized symptom monitor (PCL-5 for adults, CATS for child/adolescent) AND demonstrated a response to treatment at six months (+/- 120 days) after the index visit.\n\nThis measure is a multi-strata measure, which addresses symptom monitoring for both child and adult patients being treated for post-traumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR8",
    "title": "Alcohol Use Disorder Outcome Response",
    "description": "The percentage of adult patients (18 years of age or older) who report problems with drinking alcohol AND with documentation of a standardized screening tool (e.g., AUDIT, AUDIT-C, DAST, TAPS) AND demonstrated a response to treatment at three months (+/- 60 days) after the index visit",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MBHR9",
    "title": "Outcome monitoring of ADHD functional impairment in children and youth",
    "description": "Percentage of children aged 4 through 18 years, with a diagnosis of attention deficit/hyperactivity disorder (ADHD), who demonstrate a change score of 0.25 or greater on the Weiss Functional Impairment Rating Scale - Parent Report (WFIRS-P) within 2 to 10 months after an initial positive finding of functional impairment.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MBHR Mental and Behavioral Health Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "4067715"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "4to18",
        "description": "The percentage of patients 4 to 18 years of age receiving a psychiatric or behavioral health intake visit  and a clinically significant, baseline WFIRS-P total mean score of 0.65 or greater."
      },
      {
        "name": "overall",
        "description": "The percentage of patients who demonstrated a positive improvement (a score reduction) of 0.25 or more points on the total mean score of the WFIRS-P assessment taken 2 to 10 months later."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEDNAX53",
    "title": "Use of Capnography for Non-Operating Room Anesthesia",
    "description": "Percentage of patients receiving anesthesia in a non-operating room setting who have end-tidal carbon dioxide (ETCO2) monitored using capnography.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5551268",
      "9881603",
      "6394618",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEDNAX54",
    "title": "Labor Epidural Failure when Converting from Labor Analgesia to Cesarean Section Anesthesia",
    "description": "The percentage of patients who have pre-existing labor epidural or combined epidural/spinal technique who require either repeat procedural epidural or spinal, general anesthesia, or supplemental sedation as defined below for cesarean section.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5551268",
      "9881603",
      "1725296",
      "7746687"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEDNAX55",
    "title": "Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.",
    "description": "Percentage non-contrast CT Head performed for suspected acute stroke whose final reports include an ASPECTS value.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "9881603",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEDNAX56",
    "title": "Use of a “PEG Test” to Manage Patients Receiving Opioids",
    "description": "Percentage of patients in an outpatient setting, aged 18 and older, in whom a stable dose of opioids are prescribed for greater than 6 weeks for pain control, and the results of a “PEG Test” are correctly interpreted and applied to the management of their opioid prescriptions.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5551268",
      "9881603"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MEX5",
    "title": "Hammer Toe Outcome",
    "description": "Percentage of patients with a who have a lesser toe deformity (hammer and claw toes) causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "4117893"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN13",
    "title": "Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery Calcification Regional Distribution Scoring",
    "description": "Percentage of patients, regardless of age, undergoing Coronary Calcium Scoring who have measurable coronary artery calcification (CAC).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "MSN15",
    "title": "Use of Thyroid Imaging Reporting & Data System (TI-RADS) in Final Report to Stratify Thyroid Nodule Risk",
    "description": "Percentage of patients, regardless of age, undergoing ultrasound of the neck with\nfindings of thyroid nodule(s) whose reports include the TI-RADS assessment.",
    "nqfId": null,
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    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
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    "metricType": "registrySinglePerformanceRate",
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      "registry"
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  },
  {
    "measureId": "MSN16",
    "title": "Screening Abdominal Aortic Aneurysm Reporting with Recommendations",
    "description": "Percentage of patients, aged 50-years-old or older, who have had a screening ultrasound for an abdominal aortic aneurysm with a positive finding of abdominal aortic aneurysm (AAA), that have recognized clinical follow up recommendations documented\nin the final report and direct communication of findings ≥ 5.5 cm in size made to the ordering provider.",
    "nqfId": null,
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    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2021,
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    "metricType": "registrySinglePerformanceRate",
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  },
  {
    "measureId": "MUSIC10",
    "title": "Prostate Cancer: Confirmation Testing in low risk AS eligible patients",
    "description": "Percentage of low risk patients that are eligible for active surveillance who receive confirmation testing within 6 months of diagnosis",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR",
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  },
  {
    "measureId": "MUSIC11",
    "title": "Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months",
    "description": "Percentage of patients on active surveillance that have ≥ 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
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  },
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    "measureId": "MUSIC12",
    "title": "Kidney Stones: ED visit within 30 days of ureteroscopy",
    "description": "Percentage of patients who underwent ureteroscopy and experienced an unplanned ED visit within 30 days of the procedure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
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    "metricType": "registrySinglePerformanceRate",
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  },
  {
    "measureId": "MUSIC15",
    "title": "Kidney Stones: SWL in patients with largest renal stone > 2 cm or lower pole stone > 1 cm",
    "description": "Percentage of patients who underwent shockwave lithotripsy with a largest renal stone > 2 cm or with a lower pole stone > 1 cm",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": true,
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    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR",
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  },
  {
    "measureId": "MUSIC17",
    "title": "Kidney Stones: Opioid utilization after ureteroscopy and shockwave lithotripsy",
    "description": "Percentage of patients who underwent ureteroscopy or shockwave lithotripsy and are discharged on NSAIDS, Acetaminophen, or \"Other\" and who were not prescribed opioids for pain control",
    "nqfId": null,
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    "isHighPriority": true,
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  },
  {
    "measureId": "MUSIC18",
    "title": "Kidney Stones: Alpha-blockers at discharge for patients undergoing ureteroscopy or shockwave lithotripsy",
    "description": "Percentage of patients who underwent ureteroscopy or shockwave lithotripsy and received alpha-blockers at discharge",
    "nqfId": null,
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    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Michigan Urological Surgery Improvement Collaborative (MUSIC) QCDR",
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  },
  {
    "measureId": "MUSIC19",
    "title": "Kidney Stones: Readmission within 30 days of ureteroscopy",
    "description": "Percentage of patients who underwent ureteroscopy and experienced a readmission within 30 days of the procedure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
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  },
  {
    "measureId": "MUSIC20",
    "title": "Prostate Cancer: Complications within 30 days of radical prostatectomy",
    "description": "Percentage of radical prostatectomy patients who do not have any deviations from an uncomplicated recovery pathway within 30 days of the procedure",
    "nqfId": null,
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    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
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  },
  {
    "measureId": "MUSIC21",
    "title": "Prostate Cancer: Opioid utilization after radical prostatectomy",
    "description": "Percentage of patients who underwent radical prostatectomy and are discharged with ≤ 6 opioid pain pills (5mg oxycodone or equivalent) and do not get a prescription for opioids within 30 days of surgery",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Community/Population Health",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
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  },
  {
    "measureId": "MUSIC22",
    "title": "Prostate Cancer: Urinary continence at 12 months post-radical prostatectomy",
    "description": "Percentage of radical prostatectomy patients that are socially continent (0 - 1 pads per day) at 12 months after surgery",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
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  {
    "measureId": "MUSIC23",
    "title": "Renal Mass: Documentation of the RENAL score for patients with small renal mass diagnoses",
    "description": "Percentage of patients diagnosed with a small renal mass (≤ 7 cm) and have their RENAL score documented in the medical record by the attending physician",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
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  },
  {
    "measureId": "MUSIC24",
    "title": "Kidney Stones: Post-ureteroscopy and shockwave lithotripsy imaging for any stones",
    "description": "Percentage of patients who underwent imaging within 60 days after ureteroscopy or shockwave lithotripsy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
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  {
    "measureId": "MUSIC25",
    "title": "Renal Mass: ED visit or Readmission within 30 days of radical nephrectomy",
    "description": "Percentage of patients with a small renal mass (≤ 7 cm) who underwent a radical nephrectomy and experienced an ED visit or readmission within 30 days of the procedure",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "outcome",
    "isHighPriority": true,
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  {
    "measureId": "MUSIC26",
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    "description": "Percentage of patients with a small renal mass (≤ 7 cm) who underwent a partial nephrectomy and experienced an ED visit or readmission within 30 days of the procedure",
    "nqfId": null,
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  {
    "measureId": "MUSIC4",
    "title": "Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients",
    "description": "Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
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  {
    "measureId": "MUSIC5",
    "title": "Prostate Cancer: Radical Prostatectomy Cases LOS",
    "description": "Percentage of radical prostatectomy cases with a length of stay > 2 days",
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    "isHighPriority": true,
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  {
    "measureId": "NHCR4",
    "title": "Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation",
    "description": "Percentage of patients recommended for repeat screening or surveillance colonoscopy within one year or less due to inadequate/poor bowel preparation quality",
    "nqfId": null,
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    "primarySteward": "New Hampshire Colonoscopy Registry (NHCR), GIQuIC",
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  {
    "measureId": "NIPM18",
    "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL LYSIS OF ADHESIONS",
    "description": "Measurement of the change in patient reported quality of life following epidural lysis of adhesions. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, and activities of daily living.",
    "nqfId": null,
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  {
    "measureId": "NIPM19",
    "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE AND FUNCTIONAL STATUS FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATION",
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    "firstPerformanceYear": 2019,
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  {
    "measureId": "NIPM20",
    "title": "CHANGE IN PATIENT REPORTED PAIN AND FUNCTIONAL STATUS FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION",
    "description": "Measurement of the change in patient reported quality of life following spinal cord stimular implantation for failed back surgery syndrome. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, psychological well-being and activities of daily living.",
    "nqfId": null,
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  {
    "measureId": "NIPM22",
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    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM23",
    "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING MAJOR JOINT CORTICOSTEROID INJECTION",
    "description": "Measurement of the change in patient reported quality of life following major joint corticosteroid injection. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, and activities of daily living.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "9752492"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM24",
    "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING INTRATHECAL PUMP IMPLANTATION",
    "description": "Measurement of the change in patient reported quality of life following intrathecal pump implantation. Quality of life measurement on standardized scale includes pain, mobility, psychological well-being, and activities of daily living.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9752492"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NIPM25",
    "title": "CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING INTERSPINOUS INDIRECT DECOMPRESSION (SPACER)",
    "description": "Measurement of the change in patient reported quality of life following interspinous indirect decompression (spacer). Quality of life measurement on standardized scale includes pain, mobility, psychological well-being, analgesic medication use, and activities of daily living.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "The ASIPP National Interventional Pain Management (NIPM) Qualified Clinical Data Registry, powered by ArborMetrix",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9752492"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR1",
    "title": "Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI)",
    "description": "Percentage of ordering providers who have ordered a myoglobin or CK-MB for greater than 10% of the patients who have a diagnosis of suspected AMI, that were informed by the laboratory these tests are not beneficial for patients with a diagnosis of suspected AMI.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR11",
    "title": "Rate of communicating results of an amended report with a major discrepancy to the responsible provider",
    "description": "Rate of communicating to the responsible provider the results of diagnostic reports that were amended due to a major discrepancy.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR13",
    "title": "Rate of notification to clinical provider of a new diagnosis of malignancy",
    "description": "The rate of reporting to a responsible clinical provider from the pathologist when there is a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin) from a pathology specimen",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR15",
    "title": "Non-small cell lung carcinoma (NSCLC) ancillary biomarker testing status and turnaround time (TAT) from point of specimen accession date to ancillary biomarker testing completion and reporting date should be ≤ 10 days",
    "description": "Percentage of lung cytopathology or pathology specimen cases with non-small cell lung carcinoma (NSCLC) that address presence or absence of actionable targets through ancillary biomarker testing\nAND\nmeet the maximum 10 day turnaround time (TAT) requirement (Report Date of ancillary biomarker testing – Accession Date = ≤ 10 days).\nThis measure has two performance rates that contribute to the overall performance score:\n1. Percent of cases in which ancillary biomarker testing for actionable targets with a diagnosis of non-small cell carcinoma is addressed.\n2. Percent of cases that meet the maximum 10 day turnaround time.\nThe overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR16",
    "title": "Notification to the provider ordering repeat blood chemistry panels in clinically stable patients within four days.",
    "description": "Percentage of providers who ordered a repeat blood chemistry panel within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR17",
    "title": "Notification to the provider ordering repeat C. difficile stool toxin testing within seven days",
    "description": "Percentage of providers who ordered repeat C. difficile stool toxin testing within seven days on an individual patient, who were notified by the laboratory that repeat testing is not beneficial, and can lead to increased false positive test results.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR18",
    "title": "Notification to the provider ordering repeat CBCs in clinically stable patients within four days",
    "description": "Percentage of providers who ordered a repeat CBC within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR19",
    "title": "Notification to the provider ordering repeat Hepatitis C serology testing on a patient with previously positive results",
    "description": "Percentage of providers who ordered repeat Hepatitis C serology testing on a patient with previously positive results, who were notified by the laboratory that repeat testing is not beneficial.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR2",
    "title": "Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorder",
    "description": "Percentage of ordering providers who ordered thyroid screening tests other than only a TSH in greater than 10% of their patients for the evaluation of a patient with suspected non-neoplastic thyroid disease, who were informed by the laboratory these tests are not beneficial for the initial diagnosis of thyroid disease.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR3",
    "title": "Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitis",
    "description": "Percentage of ordering providers who ordered an amylase test in greater than 10% of their patients for the evaluation of a patient with acute pancreatitis, who were informed by the laboratory this test is not beneficial for the diagnosis of pancreatitis.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR4",
    "title": "Time interval: critical value reporting for chemistry",
    "description": "Measurement of the time interval beginning with the time results are verified for any of the following Sodium, Potassium, Chloride, Calcium-total, Bicarbonate – CO2, Ammonia, Total Bilirubin – Newborn, Glucose, Glucose – Newborn tests until the critical value is reported by the laboratory. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received, this should be considered as performance not met.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR5",
    "title": "Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC)",
    "description": "Measurement of the time interval beginning with the time results are verified (clinical) until the critical value is reported by the laboratory for CSF-WBC. (Done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR6",
    "title": "Time interval: critical value reporting for toxicology",
    "description": "Measurement of the time interval beginning with the time results are verified until the critical value is reported by the laboratory for Carbamazepine, Phenobarbital, and Acetaminophen toxicology tests. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "NPQR7",
    "title": "Time interval: critical value reporting for troponin",
    "description": "Measurement of the time interval beginning with the time results are verified for Troponin (CPT - 84484) until the critical value is reported by the laboratory. (Reporting done via phone, email with read receipt functionality, or text). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "National Pathology Quality Registry (NPQR)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "9391953"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "nonProportion",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OBERD32",
    "title": "Quality of Life - Physical Health Outcomes",
    "description": "Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OEIS6",
    "title": "Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention",
    "description": "Proportion of patients with non-invasive evaluations present/available prior to LE peripheral vascular interventions in patients with intermittent claudication.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society National Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "7689991"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OEIS7",
    "title": "Structured Walking Program Prior to Intervention for Claudication",
    "description": "Proportion of patients who completed a structured walking program of a duration not less than 12 weeks prior to undergoing peripheral arterial intervention in patients with claudication",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society National Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "7689991"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "OEIS8",
    "title": "Use of ultrasound guidance for vascular access",
    "description": "Proportion of vascular access using ultrasound guidance for vessel puncture during endovascular procedures.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Outpatient Endovascular and Interventional Society National Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "7689991"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR21",
    "title": "Patient Reported Health-Related Quality of Life (HRQoL) during Treatment for Advanced Cancer",
    "description": "Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life. Two rates are reported: 1. Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart. 2. Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Clinician Performance Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "diagnosis",
        "description": "The first is patients with active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart;"
      },
      {
        "name": "overall",
        "description": "The second measure is the performance measure of the recent score indicates the same or better quality of life."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR22",
    "title": "PCR Test with MR2 or greater result (BCR-ABL1 transcript level <= 1% [IS]) for patients receiving TKI for at least 6 months for Chronic Myelogenous Leukemia",
    "description": "Percentage of patients aged 18 and older with chronic myelogenous leukemia who are receiving TKI therapy for at least 6 months, who have at least 1 PCR test performed with the most recent result equal to or greater than MR2 (BCR-ABL1 transcript level <= 1% [IS]) during the measurement period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Clinician Performance Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "ONSQIR23",
    "title": "Assessment for and management of immune-related adverse events during cancer treatment with checkpoint inhibitors (ICPi)",
    "description": "Percentage of patients aged 18 and older receiving a checkpoint inhibitor (ICPi) for cancer experiencing immune-related adverse events of documented grade 3+ diarrhea OR documented grade 3+ hypothyroidism OR documented grade 3+ dermatitis OR documented grade 3+ pneumonitis AND for each adverse event, there is guideline concordant intervention (per ASCO/NCCN guideline) during the measurement period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Clinician Performance Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH1",
    "title": "Oncology: Advance Care Planning in metastatic cancer patients",
    "description": "Percentage of patients with metastatic (stage 4) cancer who have a documented Advance Care Planning discussion in the first 6 months after metastatic diagnosis to inform treatment decisions and end-of-life care.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "patientEngagementExperience",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH10",
    "title": "Oncology: Hepatitis B serology testing and prophylactic treatment prior to receiving anti-CD20 targeting drugs",
    "description": "Percentage of patients tested for Hepatitis B prior to receiving anti-CD20 targeting treatment, including rituximab, ofatumumab, and obinutuzumab; patients testing positive for Hepatitis B receive prophylactic treatment.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH11",
    "title": "Oncology: Utilization of PET, PET/CT, or CT scans for breast cancer stage 0, I, or II at any time during the course of evaluation and treatment",
    "description": "Percentage of female breast cancer patients stage 0, I, or II with curative treatment intent (including observation, adjuvant chemotherapy, radiation or surgery) who receive a PET, PET/CT or CT scan as part of initial staging, treatment,  or routine surveillance",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH2",
    "title": "Oncology: Utilization of GCSF in metastatic colorectal cancer",
    "description": "Percentage of Stage 4 colon/rectal cancer patients receiving any white cell growth factors with chemotherapy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH3",
    "title": "Oncology: Combination chemotherapy recommended or received within 4 months of diagnosis by women under 70 with AJCC stage T1cN0M0 to Stage 1B-III ER/PR negative breast cancer",
    "description": "Percentage of female patients, age >18 at diagnosis, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC Stage T1cN0M0 (tumor greater than 1cm), or Stage 1B-III, whose primary tumor is progesterone and estrogen receptor negative recommended for multi-agent chemotherapy (recommended or administered) within 4 months (120 days) of diagnosis",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH4",
    "title": "Oncology: Patient-reported pain improvement",
    "description": "Percentage of cancer patients currently receiving chemotherapy or radiation therapy who report significant pain improvement (high to moderate, moderate to low, or high to low) within 30 days",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH8",
    "title": "Oncology: Mutation testing for lung cancer completed prior to start of targeted therapy",
    "description": "Proportion of stage 4 NSCLC patients tested for actionable biomarkers, including EGFR, BRAF mutation; ROS1, ALK rearrangement; PD-L1 expression, and received targeted therapy or chemotherapy based on biomarker results.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PIMSH9",
    "title": "Oncology: Supportive care drug utilization in last 14 days of life",
    "description": "Percentage of patients receiving supportive care drugs (including colony stimulating factors, bone health, supplemental iron medications, and neurokinin 1 (NK1) receptor antagonist antiemetics) during the 14 days prior to and including the date of death.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "efficiency",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "8794712"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PINC55",
    "title": "Appropriate Documentation of a Malnutrition Diagnosis",
    "description": "Percentage of patients age 18 years and older who are found to be severely or moderately malnourished based on a nutrition assessment that have appropriate documentation in the medical record of a malnutrition diagnosis",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Clinician Performance Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PINC56",
    "title": "Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist",
    "description": "Percentage of patients age 18 years and older who are nutritionally at-risk that have documented nutrition intervention recommendations by a registered dietitian nutritionist or clinical qualified nutrition professional if identified with moderate or severe malnutrition as part of a nutrition assessment",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Premier Clinician Performance Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "1284980"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PP8",
    "title": "Measurement-based Care Processes: Baseline Assessment, Monitoring and Treatment Adjustment",
    "description": "Percentage of individuals 18 years of age and older with a diagnosis of mental and/or substance abuse disorder, who had a baseline assessment with ongoing monitoring, AND who had an adjustment to their care plan following assessment and monitoring. Three rates are reported. \n\na. Percentage of individuals who had a baseline assessment in at least five (5) mental health domains including depression, anxiety, substance use, suicide risk and psychosis, as well as an assessment of functioning and recovery.\n\nb. Percentage of individuals who had a baseline assessment, who were monitored with follow-up for improvement or maintenance of symptom severity, functioning and recovery.\n\nc. Percentage of individuals who had a baseline assessment AND who had documentation of a clinical decision to adjust (or no adjustment) their care plan, including an adjustment to their medication OR therapy; OR referral OR consultation, following monitoring.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "PsychPRO",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4078845"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "simpleAverage",
    "strata": [
      {
        "name": "assessment",
        "description": "Percentage of individuals (aged 18+ years) with baseline assessment in 5 mental health domains (depression, anxiety, substance use, suicide ideation and psychosis); and for function and recovery."
      },
      {
        "name": "followUp",
        "description": "Percentage of individuals (aged 18+ years) monitored with follow-up for improvement or maintenance of symptom severity, functioning and recovery based on results from validated assessment tools."
      },
      {
        "name": "adjustment",
        "description": "Percentage of individuals (aged 18+ years) whose clinician used their data from validated tools, to make decisions about adjustments to their care plan."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "PP9",
    "title": "Improvement or Maintenance of Functioning for Individuals with a Mental Health and/or Substance Use Disorder",
    "description": "The percentage of individuals aged 18 and older with a mental and/or substance use disorder who demonstrated an improvement in functioning (or maintained baseline level of functioning) based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) 180 days (+/- 30 days) after a baseline visit.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "PsychPRO",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4078845"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QMM16",
    "title": "IVC Filter Management Confirmation",
    "description": "Percentage of final reports for eligible exams where an IVC filter is present and the radiologist included a statement of recommendation in the impression of the report for the treating clinician to:\n1) Assess if there is a management plan in place for the patient’s IVC filter, \nAND \n2) If there is no established management plan for the patient’s IVC filter, refer the patient to an interventional clinician on a nonemergent basis for evaluation.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR, MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "9881603",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QMM17",
    "title": "Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS)",
    "description": "The percentage of final reports for female patients receiving a transvaginal ultrasound (US) examination of the pelvis (including transabdominal/transvaginal exams) where a clinically relevant lesion is detected, in which the radiologist describes the lesion using O-RADS Lexicon Descriptors and subsequently makes the correct clinical management recommendation based on the O-RADS Risk Stratification and Management System.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR, MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "9881603",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QMM18",
    "title": "Use of Breast Cancer Risk Score on Mammography",
    "description": "The percentage of final reports for screening mammograms which include the patient’s estimated numeric risk assessment based on published guidelines, and appropriate recommendations for supplemental screening based on the patient’s estimated risk and documentation of the source of recommendation.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR, MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "9881603",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QMM19",
    "title": "DEXA/DXA and Fracture Risk Assessment for Patients with Osteopenia",
    "description": "All patients, aged 40-90 at time of service, who undergo DEXA scans for bone density who have their FRAX score included in the final report.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR, MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "9881603",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QMM20",
    "title": "Opening Pressure in Lumbar Puncture",
    "description": "Percentage of final reports for patients aged ≥ 18 which include Documentation of Opening Pressure Value obtained during Lumbar Puncture",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR, MSN Healthcare Solutions, LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "9881603",
      "6394618"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QOPI23",
    "title": "Concurrent Chemo radiation for Patients with a Diagnosis of Stage IIIB NSCLC",
    "description": "Percentage of patients, regardless of age, with a diagnosis of Stage IIIB non-small cell lung cancer (NSCLC) receiving concurrent chemoradiation.",
    "nqfId": null,
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    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "POLARIS QCDR in collaboration with the American Society of Clinical Oncology",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5792497"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
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      "registry"
    ]
  },
  {
    "measureId": "QOPI26",
    "title": "Sentinel Lymph Node (SLN) Biopsies for Patients AJCC T1b-T4 Melanoma",
    "description": "Percentage of patients, aged 18 and older, with a diagnosis of AJCC T1b-T4 cutaneous melanoma who received a SLN biopsy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "POLARIS QCDR in collaboration with the American Society of Clinical Oncology",
    "firstPerformanceYear": 2020,
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      "5792497"
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      "pcf"
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "QOPI27",
    "title": "Appropriate Antiemetic Therapy for High- and Moderate Emetic Risk Antineoplastic Agents",
    "description": "Percentage of cancer patients aged ≥18 years treated with high- or moderate-emetic risk antineoplastic agents who are administered appropriate pre-treatment antiemetic therapy\n\nThe overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
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    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "POLARIS QCDR in collaboration with the American Society of Clinical Oncology",
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      "5792497"
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      "cpcPlus",
      "pcf"
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "QUANTUM31",
    "title": "Central Line Ultrasound Guidance",
    "description": "Percentage of patients, regardless of age, in whom ultrasound guidance is used by the anesthesia clinician when placing a central line for those central lines that are placed in the internal jugular location.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Patient Safety",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "MEDNAX QCDR",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "5551268",
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      "6775913",
      "9881603",
      "6394618",
      "1725296",
      "7746687"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR10",
    "title": "Upper Extremity Edema Improvement",
    "description": "Upper Extremity Edema Improvement is the percentage of procedures for patients with ESRD that present with upper\nextremity edema and report an improvement within 48 hours after an intervention has been performed.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "4302083"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR12",
    "title": "Tunneled Hemodialysis Catheter Success",
    "description": "Tunneled Hemodialysis Catheter Success is the percentage of patients with ESRD that had insertion or replacement of a central venous access device during the past 12 months who received a full dialysis treatment within 72 hours of catheter insertion or replacement.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "4302083"
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      "pcf"
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    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
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      "registry"
    ]
  },
  {
    "measureId": "RCOIR13",
    "title": "Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate",
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    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4302083"
    ],
    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
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    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR5",
    "title": "End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care",
    "description": "End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care is the percentage of all adult ESRD patients on peritoneal dialysis (PD) or home hemodialysis.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2017,
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      "4302083"
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      "cpcPlus",
      "pcf"
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    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RCOIR7",
    "title": "Improved Access Site Bleeding",
    "description": "Improved Access Site Bleeding is the percentage of interventions for patients with ESRD and a vascular access site that presented for prolonged bleeding, and who post-intervention reported a reduction in bleeding",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
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      "pcf"
    ],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "REGCLR1",
    "title": "Heel Pain Treatment Outcomes for Adults",
    "description": "Percentage of patients aged 18 and older with a diagnosis of heel pain who receive an intervention intended to treat the heel pain and experience a clinically significant decrease in heel pain.\nPatients who have had at least two visits during the reporting period",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "REGCLR2",
    "title": "Tendinitis/ Enthesopathy- Injection Treatment Outcomes for Adults",
    "description": "Percentage of patients aged 18 or older with a diagnosis of Tendinitis that have a reduction in pain after injection therapy",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
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      "cpcPlus",
      "pcf"
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    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "REGCLR3",
    "title": "Bunion Outcome - Adult and Adolescent",
    "description": "Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4117893"
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      "pcf"
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    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "REGCLR4",
    "title": "Heel Pain Treatment Outcomes for Pediatric Patients",
    "description": "Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who receive an intervention intended to treat the heel pain and experience a clinically significant decrease in heel pain.\nPatients who have had at least two visits during the reporting period",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4117893"
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      "pcf"
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
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  },
  {
    "measureId": "REGCLR5",
    "title": "Offloading with Remote Monitoring",
    "description": "Percentage of patients with a plantar foot ulcer who were compliant with offloading and healed their ulcer in 10 (ten) weeks.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
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      "cpcPlus",
      "pcf"
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    "isIcdImpacted": false,
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    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "REGCLR6",
    "title": "Use of Digital Imaging to Monitor and Improve Treatment Outcomes in Chronic Wound Healing",
    "description": "This measure is specifically for CHRONIC wounds. Those are wounds that have been present for an extended period of time and have not demonstrated healing. \nPercentage of patients presenting with a non-healing (chronic) wound (present for 6 weeks with no or limited response to treatment) who are currently visiting a provider responsible for their wound care, whose provider is using a software-based wound surface area measurement tool, and whose wound healing rate has accelerated since their provider’s adoption of said tool.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4117893"
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    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "REGCLR7",
    "title": "Use of Ankle Foot Orthotics to improve patient function",
    "description": "This measures the improvement in function of patient who are prescribed foot and ankle braces for plantar fasciitis, Posterior Tibial Tendon Dysfunction, and ankle sprains",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Registry Clearinghouse LLC",
    "firstPerformanceYear": 2021,
    "allowedVendors": [
      "4117893"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR13",
    "title": "Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) and who are undergoing maintenance hemodialysis or peritoneal dialysis in an outpatient dialysis facility and for whom documentation is sent to the dialysis unit or referring physician within two business days of the procedure completion or consultation by an interventional nephrologist, radiologist, or vascular surgeon.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "4302083"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR14",
    "title": "Arteriovenous Graft Thrombectomy Success Rate",
    "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients aged 18 years and older.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "4302083"
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      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR15",
    "title": "Arteriovenous Fistulae Thrombectomy Success Rate",
    "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients aged 18 years and older on maintenance hemodialysis dialysis",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "4302083"
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      "cpcPlus",
      "pcf"
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    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR16",
    "title": "Peritoneal Dialysis Catheter Success Rate",
    "description": "Percentage of clinically successful peritoneal dialysis (PD) catheter placements in patients aged 18 and older.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
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      "pcf"
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    "lastPerformanceYear": null,
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    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR18",
    "title": "Advance Directives Completed",
    "description": "Percentage of patients aged 18 years and older with a diagnosis of Stage 3, 4 & 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) who have advance directives and/or end of life medical orders (e.g., POLST, MOLST, MOST, POST, etc.) completed based on their preferences.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2016,
    "allowedVendors": [
      "4302083"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "RPAQIR5",
    "title": "Transplant Referral",
    "description": "Percentage of patients aged 18 -75 years old with a diagnosis of end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis for 90 days or longer who are referred to a transplant center for kidney transplant evaluation within a 12-month period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Communication and Care Coordination",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
    "lastPerformanceYear": null,
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    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINETRACK4",
    "title": "Percent of patients meeting SCB thresholds for back or neck pain",
    "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5224253"
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    "allowedPrograms": [
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      "cpcPlus",
      "pcf"
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    "category": "quality",
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    ]
  },
  {
    "measureId": "SPINETRACK5",
    "title": "Percent of patients meeting SCB thresholds for leg or arm pain",
    "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in leg or arm pain following a spine surgical intervention (cervical or lumbar)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINETRACK6",
    "title": "Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)",
    "description": "Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINETRACK8",
    "title": "Patient satisfaction following spinal fusion surgery",
    "description": "Calculation of the percent of patients who are 'Very satisfied' or 'Somewhat satisfied' with their surgical outcome following a spine surgical intervention (cervical or lumbar).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "SPINETRACK9",
    "title": "Unplanned hospital readmission following spinal fusion surgery.",
    "description": "Calculation of the percent of patients who require unplanned hospital readmission following spine surgical intervention (cervical or lumbar).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": false,
    "primarySteward": "AAOS Orthopaedic Quality Resource Center",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "5224253"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "STS1",
    "title": "Prolonged Length of Stay Following Coronary Artery Bypass Grafting",
    "description": "Percentage of patients aged 18 years and older undergoing isolated CABG with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": true,
    "isRiskAdjusted": true,
    "primarySteward": "STS National Database",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "7868157"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "STS7",
    "title": "Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery",
    "description": "Percentage of patients age 18 and older undergoing a non-emergency risk modeled cardiac surgery procedure that had personalized risk assessment using the STS risk calculator and discussed those risks with the surgeon.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "STS National Database",
    "firstPerformanceYear": 2015,
    "allowedVendors": [
      "7868157"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "UREQA1",
    "title": "Ankylosing Spondylitis: Controlled Disease",
    "description": "Percentage of qualifying visits for patients aged 18 years and older with a diagnosis of ankylosing spondylitis for at least 6 months whose most recent BASDAI score is less than 4.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "1649514"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "UREQA2",
    "title": "Ankylosing Spondylitis: Appropriate Pharmacologic Therapy",
    "description": "Percentage of patients aged 18 years and older with a first diagnosis of ankylosing spondylitis who are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) before initiation of biologic therapy.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Efficiency and Cost Reduction",
    "measureType": "process",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "1649514"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "UREQA4",
    "title": "Folic or Folinic Acid Therapy for Patients Treated with Methotrexate",
    "description": "Percentage of patients aged 18 years and older being treated with methotrexate who are concomitantly treated with folic or folinic acid.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics)",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "1649514"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR22",
    "title": "Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers",
    "description": "The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA by Nestlé) within the 12-month reporting period.\n\t\nUsing the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. Patients may be provided with a variety of options for supplementation from which to chose that would provide the recommended number of calories or nutritional content. A follow up plan is documented during the encounter from the patient reported nutritional assessment.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2017,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR23",
    "title": "Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential",
    "description": "Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by severity of arterial disease (as measured via ABI, perfusion pressure, or transcutaneous oximetry) .\n\nThere are four rates reported for this measure. The four rates will be risk stratified into three buckets which are the following:\n1.\tNo evidence of arterial disease and ischemia is not a contributor to non-healing\n2.\tPossible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s) and does not require referral to a vascular specialist.\n3.\tEvidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal.\n4.\tThe average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registryMultiPerformanceRate",
    "overallAlgorithm": "overallStratumOnly",
    "strata": [
      {
        "name": "noevidence",
        "description": "No evidence of arterial disease and ischemia is not a contributor to non-healing"
      },
      {
        "name": "possiblecompromise",
        "description": "Possible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s)"
      },
      {
        "name": "evidence",
        "description": "Evidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal."
      },
      {
        "name": "overall",
        "description": "The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted."
      }
    ],
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR24",
    "title": "Patient Reported Experience of Care: Wound Outcome",
    "description": "All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "patientReportedOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2018,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR25",
    "title": "Pressure Ulcer* (PU) Healing or Closure for ulcers on the torso (body)",
    "description": "Percentage of Stage 2, 3, or 4 pressure ulcers* (not on the lower extremity) among patients age 18 or older that achieve healing or closure within 6 months, stratified by the Wound Healing Index (WHI). Healing or closure may occur by delayed secondary intention or may be the result of surgical intervention (e.g. rotational flap or skin graft). Lower extremity pressure ulcers are not included in this measure because they commonly overlap with arterial and diabetic foot ulcers and require a separate risk stratification model.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": true,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR26",
    "title": "Patient Reported Outcome of late effects of radiation symptoms following treatment with Hyperbaric Oxygen Therapy (HBOT)",
    "description": "The percentage of patients 18 or older undergoing 10 or more treatments with HBOT for late effects of radiation whose self reported symptoms improve by at least 2 categories on the appropriate questionnaire (e.g. the Hematuria classification scale, the Chandler grade, the Cystitis questionnaire, the Bowel questionnaire, the head and neck questionnaire).",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Person and Caregiver Centered Experience and Outcomes",
    "measureType": "outcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2019,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR27",
    "title": "Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist",
    "description": "Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "USWR28",
    "title": "Obtaining Preoperative Nutritional Recommendations from a Registered Dietitian Nutritionist (RDN) in Nutritionally At-Risk Surgical Patients",
    "description": "Percentage of patients age 18 years and older who have undergone a surgical procedure and were identified to be at-risk for malnutrition based on a malnutrition screening OR who were referred to a registered dietitian nutritionist or clinically qualified nutrition professional and have a preoperative nutrition assessment which was documented in the medical record along with documentation of any recommended nutrition interventions.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "U.S. Wound Registry",
    "firstPerformanceYear": 2020,
    "allowedVendors": [
      "6853338"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "WCHQ10",
    "title": "Diabetes Care All or None Outcome Measure: Optimal Control",
    "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: \n All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <130/80, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "intermediateOutcome",
    "isHighPriority": true,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Physician Compass",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "9431047"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  },
  {
    "measureId": "WCHQ9",
    "title": "Diabetes Care All or None Process Measure: Optimal Testing",
    "description": "The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: \n All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function \nMonitoring Test and one eGFR Test",
    "nqfId": null,
    "nationalQualityStrategyDomain": "Effective Clinical Care",
    "measureType": "process",
    "isHighPriority": false,
    "isInverse": false,
    "isRiskAdjusted": false,
    "primarySteward": "Physician Compass",
    "firstPerformanceYear": 2014,
    "allowedVendors": [
      "9431047"
    ],
    "allowedPrograms": [
      "mips",
      "cpcPlus",
      "pcf"
    ],
    "category": "quality",
    "lastPerformanceYear": null,
    "eMeasureId": null,
    "nqfEMeasureId": null,
    "measureSets": [],
    "isRegistryMeasure": true,
    "isIcdImpacted": false,
    "metricType": "registrySinglePerformanceRate",
    "submissionMethods": [
      "registry"
    ]
  }
]