[ { "title": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)", "eMeasureId": "CMS122v8", "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, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "preventiveMedicine", "nephrology", "endocrinology", "nutritionDietician" ], "measureSpecification": {} }, { "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS135v8", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureId": "005", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "hospitalists" ], "measureSpecification": {} }, { "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0067", "measureId": "006", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": {} }, { "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)", "eMeasureId": "CMS145v8", "nqfEMeasureId": "0070e", "nqfId": "0070", "measureId": "007", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": {} }, { "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS144v8", "nqfEMeasureId": "0083e", "nqfId": "0083", "measureId": "008", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "hospitalists", "skilledNursingFacility" ], "measureSpecification": {} }, { "title": "Anti-Depressant Medication Management", "eMeasureId": "CMS128v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "009", "description": "Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": {}, "strata": [ { "name": ">=84Days", "description": "Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks)." }, { "name": ">=180Days", "description": "Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)" } ] }, { "title": "Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation", "eMeasureId": "CMS143v8", "nqfEMeasureId": "0086e", "nqfId": "0086", "measureId": "012", "description": "Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Age-Related Macular Degeneration (AMD): Dilated Macular Examination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0087", "measureId": "014", "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care", "eMeasureId": "CMS142v8", "nqfEMeasureId": "0089e", "nqfId": "0089", "measureId": "019", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second-Generation Cephalosporin", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0268", "measureId": "021", "description": "Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Plastic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "orthopedicSurgery", "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery", "thoracicSurgery", "neurosurgical" ], "measureSpecification": {} }, { "title": "Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "023", "description": "Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Plastic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "orthopedicSurgery", "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "neurosurgical" ], "measureSpecification": {} }, { "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, "measureId": "024", "description": "Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "orthopedicSurgery", "preventiveMedicine", "rheumatology" ], "measureSpecification": {} }, { "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureId": "039", "description": "Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.", "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": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "preventiveMedicine", "rheumatology", "geriatrics", "endocrinology" ], "measureSpecification": {} }, { "title": "Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0236", "measureId": "044", "description": "Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": {} }, { "title": "Advance Care Plan", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureId": "047", "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "gastroenterology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "neurology", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "oncology", "hospitalists", "rheumatology", "nephrology", "geriatrics", "skilledNursingFacility", "pulmonology" ], "measureSpecification": {} }, { "title": "Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "048", "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.", "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": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "urology", "geriatrics" ], "measureSpecification": {} }, { "title": "Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "050", "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "urology", "geriatrics" ], "measureSpecification": {} }, { "title": "Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0102", "measureId": "052", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Thoracic Society", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pulmonology" ], "measureSpecification": {} }, { "title": "Appropriate Treatment for Children with Upper Respiratory Infection (URI)", "eMeasureId": "CMS154v8", "nqfEMeasureId": null, "nqfId": "0069", "measureId": "065", "description": "Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "familyMedicine", "otolaryngology", "pediatrics", "urgentCare" ], "measureSpecification": {} }, { "title": "Appropriate Testing for Children with Pharyngitis", "eMeasureId": "CMS146v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "066", "description": "Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "pediatrics", "urgentCare" ], "measureSpecification": {} }, { "title": "Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "067", "description": "Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Hematology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": {} }, { "title": "Hematology: Multiple Myeloma: Treatment with Bisphosphonates", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "069", "description": "Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Hematology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": {} }, { "title": "Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "070", "description": "Percentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": {} }, { "title": "Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2726", "measureId": "076", "description": "Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Anesthesiologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "anesthesiology", "interventionalRadiology", "hospitalists" ], "measureSpecification": {} }, { "title": "Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0654", "measureId": "093", "description": "Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "pediatrics", "urgentCare" ], "measureSpecification": {} }, { "title": "Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients", "eMeasureId": "CMS129v9", "nqfEMeasureId": "0389e", "nqfId": "0389", "measureId": "102", "description": "Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam 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"firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": {} }, { "title": "Elder Maltreatment Screen and Follow-Up Plan", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "181", "description": "Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 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false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": {} }, { "title": "HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0409", "measureId": "205", "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": "Health Resources and Services Administration", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": 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The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). 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, 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": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": {} }, { "title": "Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0424", "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) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). 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, 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": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": {} }, { "title": "Functional Status Change for Patients with Low Back Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0425", "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 Low Back FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). 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, and at the clinic level by 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": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": {} }, { "title": "Functional Status Change for Patients with Shoulder Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0426", "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 Shoulder FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.).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, 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": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": {} }, { "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0427", "measureId": "222", "description": "A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.) 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, 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": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": {} }, { "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, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": {} }, { "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "eMeasureId": "CMS138v8", "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 24 months AND who received tobacco cessation intervention if identified as a tobacco usera. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 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 24 months AND who received tobacco cessation intervention if identified as a tobacco user.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "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": {}, "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" }, { "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" }, { "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" } ] }, { "title": "Controlling High Blood Pressure", "eMeasureId": "CMS165v8", "nqfEMeasureId": null, "nqfId": "0018", "measureId": "236", "description": "Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "vascularSurgery", "rheumatology", "endocrinology", "pulmonology" ], "measureSpecification": {} }, { "title": "Use of High-Risk Medications in the Elderly", "eMeasureId": "CMS156v8", "nqfEMeasureId": null, "nqfId": "0022", "measureId": "238", "description": "Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.1) Percentage of patients who were ordered at least one high-risk medication.2) Percentage of patients who were ordered at least two of the same high-risk medications.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "internalMedicine", "rheumatology", "geriatrics", "pulmonology" ], "measureSpecification": {}, "strata": [ { "name": "overall", "description": "Percentage of patients who were ordered at least one high-risk medication" }, { "name": "2+", "description": "Percentage of patients who were ordered at least two of the same high-risk medication" } ] }, { "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents", "eMeasureId": "CMS155v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "239", "description": "Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.- Percentage of patients with height, weight, and body mass index (BMI) percentile documentation.- Percentage of patients with counseling for nutrition.- Percentage of patients with counseling for physical activity.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "nutritionDietician" ], "measureSpecification": {}, "strata": [ { "name": "BMI", "description": "Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement period" }, { "name": "nutrition", "description": "Patients who had counseling for nutrition during a visit that occurs during the measurement period" }, { "name": "physicalActivity", "description": "Patients who had counseling for physical activity during a visit that occurs during the measurement period" } ] }, { "title": "Childhood Immunization Status", "eMeasureId": "CMS117v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "240", "description": "Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics" ], "measureSpecification": {} }, { "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0643", "measureId": "243", "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American College of Cardiology Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "title": "Barrett's Esophagus", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1854", "measureId": "249", "description": "Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "College of American Pathologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": {} }, { "title": "Radical Prostatectomy Pathology Reporting", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1853", "measureId": "250", "description": "Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "College of American Pathologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology", "oncology" ], "measureSpecification": {} }, { "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "254", "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American College of Emergency Physicians", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": {} }, { "title": "Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "258", "description": "Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": {} }, { "title": "Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "259", "description": "Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": {} }, { "title": "Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "260", "description": "Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": {} }, { "title": "Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "261", "description": "Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Audiology Quality Consortium", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "audiology" ], "measureSpecification": {} }, { "title": "Sentinel Lymph Node Biopsy for Invasive Breast Cancer", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "264", "description": "The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Breast Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ], "measureSpecification": {} }, { "title": "Biopsy Follow-Up", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "265", "description": "Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "obstetricsGynecology", "otolaryngology", "urology" ], "measureSpecification": {} }, { "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "268", "description": "Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "neurology" ], "measureSpecification": {} }, { "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "275", "description": "Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": {} }, { "title": "Sleep Apnea: Severity Assessment at Initial Diagnosis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "277", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "otolaryngology", "pulmonology" ], "measureSpecification": {} }, { "title": "Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "279", "description": "Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "otolaryngology", "pulmonology" ], "measureSpecification": {} }, { "title": "Dementia: Cognitive Assessment", "eMeasureId": "CMS149v8", "nqfEMeasureId": "2872e", "nqfId": null, "measureId": "281", "description": "Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": {} }, { "title": "Dementia: Functional Status Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "282", "description": "Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": {} }, { "title": "Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "283", "description": "Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "geriatrics", "clinicalSocialWork" ], "measureSpecification": {} }, { "title": "Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "286", "description": "Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "geriatrics", "clinicalSocialWork" ], "measureSpecification": {} }, { "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "288", "description": "Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": {} }, { "title": "Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "290", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for psychiatric symptoms in the past 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": {} }, { "title": "Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "291", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": {} }, { "title": "Parkinson's Disease: Rehabilitative Therapy Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "293", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 months.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": {} }, { "title": "Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1536", "measureId": "303", "description": "Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "304", "description": "Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment", "eMeasureId": "CMS137v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "305", "description": "Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis.b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics" ], "measureSpecification": {}, "strata": [ { "name": "14DaysOfDiagnosis", "description": "Patients who initiated treatment within 14 days of the diagnosis" }, { "name": "30DaysOfVisit", "description": "Patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit" } ] }, { "title": "Cervical Cancer Screening", "eMeasureId": "CMS124v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "309", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed every 3 years* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.", "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": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": {} }, { "title": "Chlamydia Screening for Women", "eMeasureId": "CMS153v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "310", "description": "Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": {} }, { "title": "Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented", "eMeasureId": "CMS22v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "317", "description": "Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, 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"category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": {} }, { "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": [], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": {} }, { "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 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"icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "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": [], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "infectiousDisease" ], "measureSpecification": {} }, { "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": 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"clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "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 Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "vascularSurgery" ], "measureSpecification": {} }, { "title": "Implantable Cardioverter-Defibrillator (ICD) Complications Rate", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "348", "description": "Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "American College of Cardiology Foundation", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ 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"isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ], "measureSpecification": {} }, { "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", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, 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"plasticSurgery", "generalSurgery" ], "measureSpecification": {} }, { "title": "Surgical Site Infection (SSI)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "357", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American College of Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery" ], "measureSpecification": {} }, { "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", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology" ], "measureSpecification": {} }, { "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, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": {} }, { "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", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": {} }, { "title": "Follow-Up Care for Children Prescribed ADHD Medication (ADD)", "eMeasureId": "CMS136v9", "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", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": {}, "strata": [ { "name": "visitWithin30Days", "description": "Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase." }, { "name": "visitAndFollowups", "description": "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." } ] }, { "title": "Depression Remission at Twelve Months", "eMeasureId": "CMS159v8", "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", "measureType": "outcome", "primarySteward": "Minnesota Community Measurement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "weightedAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics", "mentalBehavioralHealth", "geriatrics", "clinicalSocialWork" ], "measureSpecification": {}, "strata": [ { "name": "12-17", "description": "Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an\r\ninitial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve\r\nmonths as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5." }, { "name": "18+", "description": "Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and an\r\ninitial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve\r\nmonths as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5." } ] }, { "title": "Closing the Referral Loop: Receipt of Specialist Report", "eMeasureId": "CMS50v8", "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", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord", "registry" ], "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": {} }, { "title": "Functional Status Assessment for Total Knee Replacement", "eMeasureId": "CMS66v8", "nqfEMeasureId": null, "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", "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": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": {} }, { "title": "Functional Status Assessment for Total Hip Replacement", "eMeasureId": "CMS56v8", "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", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": {} }, { "title": "Functional Status Assessments for Congestive Heart Failure", "eMeasureId": "CMS90v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "377", "description": "Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "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": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "title": "Children Who Have Dental Decay or Cavities", "eMeasureId": "CMS75v8", "nqfEMeasureId": null, "nqfId": null, "measureId": "378", "description": "Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "dentistry" ], "measureSpecification": {} }, { "title": "Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists", "eMeasureId": "CMS74v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "379", "description": "Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "dentistry" ], "measureSpecification": {} }, { "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "eMeasureId": "CMS177v8", "nqfEMeasureId": "1365e", "nqfId": null, "measureId": "382", "description": "Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth", "clinicalSocialWork" ], "measureSpecification": {} }, { "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "measureId": "383", "description": "Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "intermediateOutcome", "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": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "clinicalSocialWork" ], "measureSpecification": {} }, { "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", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "385", "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", "measureType": "outcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "eMeasureId": null, "nqfEMeasureId": null, "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", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": {} }, { "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": "Physician Consortium for Performance Improvement Foundation (PCPI)", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": {} }, { "title": "Cataract Surgery: Difference Between Planned and Final Refraction", "eMeasureId": null, "nqfEMeasureId": null, "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", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": {} }, { "title": "Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "390", "description": "Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": {} }, { "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", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": {}, "strata": [ { "name": "30days", "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", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "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", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": {}, "strata": [ { "name": "18-64F", "description": "Females 18-64 years of age" }, { "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", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": {} }, { "title": "Immunizations for Adolescents", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1407", "measureId": "394", "description": "The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "pediatrics" ], "measureSpecification": {}, "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, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": {} }, { "title": "Lung Cancer Reporting (Resection Specimens)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, 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"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.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "University of Southern California", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "physicalMedicine", "mentalBehavioralHealth" ], "measureSpecification": {} }, { "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.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": {} }, { "title": "Functional Status After Primary Total Knee Replacement", "eMeasureId": null, "nqfEMeasureId": null, "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) at one year (9 to 15 months) postoperatively.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": {} }, { "title": "Functional Status After Lumbar Discectomy/Laminectomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "471", "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.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": {} }, { "title": "Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture", "eMeasureId": "CMS249v2", "nqfEMeasureId": null, "nqfId": null, "measureId": "472", "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", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": {} }, { "title": "Leg Pain After Lumbar Fusion", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "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.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": {} }, { "title": "HIV Screening", "eMeasureId": "CMS349v2", "nqfEMeasureId": null, "nqfId": null, "measureId": "475", "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", "measureType": "process", "primarySteward": "Centers for Disease Control and Prevention", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "infectiousDisease" ], "measureSpecification": {} }, { "title": "International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia", "eMeasureId": "CMS771v1", "nqfEMeasureId": null, "nqfId": null, "measureId": "476", "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", "measureType": "patientReportedOutcome", "primarySteward": "Large Urology Group Practice Association and Oregon Urology Institute", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology", "geriatrics" ], "measureSpecification": {} }, { "title": "Multimodal Pain Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "477", "description": "Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Anesthesiologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": {} }, { "title": "Functional Status Change for Patients with Neck Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "478", "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+ with neck impairments. 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