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"code": "3046F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] }, { "optionType": "performanceMet", "qualityCodes": [ { "code": "3046F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3044F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9687" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2081" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2090" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G2091" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G2089" } ] } ] }, { "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 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"registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "hospitalists" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms135v8", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_005_MIPSCQM.pdf" }, "eMeasureUuid": "40280382-6963-bf5e-0169-7d10cd6f0f3f", "strata": [ { "name": "Within12Months", "description": "Patients who were prescribed ACE inhibitor or ARB or ARNI therapy within a 12-month period when seen in the outpatient setting", "eMeasureUuids": { "initialPopulationUuid": "6D023944-ABF3-4F2C-A4E4-ADB2DDCD8478", "denominatorUuid": "EFBCE92A-D635-4000-9C4F-EDD98AF5DE06", "numeratorUuid": "440B9AB7-C94C-44D8-8A8F-DDBA5E1A5226", "denominatorExceptionUuid": "57C66872-B1B4-4542-ACA6-7A309F99BDCD" } }, { "name": "HospitalDischarge", "description": "Patients who were prescribed ACE inhibitor or ARB or ARNI therapy at each hospital discharge", "eMeasureUuids": { 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false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_006_MIPSCQM.pdf" } }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms145v8", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_007_MIPSCQM.pdf" }, "eMeasureUuid": "40280382-6963-bf5e-0169-6e62c160040e", "strata": [ { "name": "LVSD", "description": "Patients with left ventricular systolic dysfunction (LVEF <40%)", "eMeasureUuids": { "initialPopulationUuid": "95AD7A85-FFC2-4176-AC65-22F0C78EB3F7", "denominatorUuid": "9A539FCC-45A6-4584-9973-6910731DD618", "numeratorUuid": "C2745442-23E2-485B-8F6A-A8AC5A166A0F", "denominatorExceptionUuid": "B50BA716-173F-46EC-B792-F031140FCD94" } }, { "name": "priorMI", "description": "Patients with a prior (within the past 3 years) myocardial infarction", "eMeasureUuids": { "initialPopulationUuid": "F86426BC-4113-4E5D-A504-582158094828", "denominatorUuid": "9A753C70-1505-4926-A628-43E99134B090", "numeratorUuid": "9F8A4285-B48A-4103-B208-73BA5E590DFC", "denominatorExceptionUuid": "D46FB5D7-9DD5-4D24-A0E3-6B4153B00D73" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms144v8" }, "eMeasureUuid": "40280382-6963-bf5e-0169-6e5d8c750401", "strata": [ { "name": "<=12Months", "description": "Patients who were prescribed beta-blocker 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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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms155v8" }, "strata": [ { 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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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms117v8" }, "eMeasureUuid": "40280382-6a17-9fbf-016a-513598af15ad", "strata": [ { "description": "Children who have evidence showing they received recommended vaccines, had documented history of 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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": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2020_Measure_250_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_250_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "C61" ], "minAge": 0, "procedureCodes": [ { "code": "88309" } ], "sexCode": "M" } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ 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"performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "1P", "2P", "3P", "8P" ] } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "2P", "3P", "8P" ], "modifiers": [ "1P" ] } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "0528F", "modifierExclusions": [ "1P", "2P", "3P" ], "modifiers": [ "8P" ] } ] } ] }, { "title": "CAHPS for MIPs Clinician/Group Survey", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005 & 0006", "measureId": "321", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. 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{ "code": "99241", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99242", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99243", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99244", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99245", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99304", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99305", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99306", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99307", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99308", "modifierExclusions": [ "GQ", "GT", "95" ], 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"modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99337", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99341", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99342", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99343", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99344", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99345", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99347", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99348", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99349", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] }, { "code": "99350", "modifierExclusions": [ "GQ", "GT", "95" ], "placesOfServiceExclusions": [ "02" ] } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G8967" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9928" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8968" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8969" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9927" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9929" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9930" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9931" } ] } ] }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_331_MIPSCQM.pdf" } }, { "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "332", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_332_MIPSCQM.pdf" } }, { "title": "Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "333", "description": "Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_333_MIPSCQM.pdf" } }, { "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "335", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_335_MIPSCQM.pdf" } }, { "title": "Maternity Care: Postpartum Follow-up and Care Coordination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "336", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care within 8 weeks of giving birth and who received a breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_336_MIPSCQM.pdf" } }, { "title": "Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "337", "description": "Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_337_MIPSCQM.pdf" } }, { "title": "HIV Viral Load Suppression", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2082", "measureId": "338", "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Health Resources and Services 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"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": [], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_340_MIPSCQM_v4.1.pdf" } }, { "title": "Pain Brought Under Control Within 48 Hours", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0209", "measureId": "342", "description": "Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "primarySteward": "National Hospice and Palliative Care Organization", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_342_MIPSCQM.pdf" } }, { "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "344", "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society for Vascular 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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_344_MIPSCQM.pdf" } }, { "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": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_348_MIPSCQM.pdf" }, "strata": [ { "name": "30", "description": "Complications or mortality at 30 days" }, { "name": "90", "description": "Complications at 90 days" } ] }, { "title": "Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "350", "description": "Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_350_MIPSCQM.pdf" } }, { "title": "Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "351", "description": "Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Association of Hip and Knee 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" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_351_MIPSCQM.pdf" } }, { "title": "Anastomotic Leak Intervention", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "354", "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.", "nationalQualityStrategyDomain": "Patient Safety", "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": [ "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_354_MIPSCQM.pdf" } }, { "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, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_355_MIPSCQM.pdf" } }, { "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "356", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "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": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_356_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_357_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_358_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_360_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_364_MIPSCQM.pdf" } }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms136v9" }, "strata": [ { "description": "Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.", "eMeasureUuids": { "initialPopulationUuid": "683F5905-CC36-4B82-AC22-38904C8298BD", "denominatorUuid": "E13D81BB-8FD5-4CE0-9885-B9BD988E1CFD", "numeratorUuid": "2720C875-C4E5-40EB-A4AE-A7B032EA9D6C", "denominatorExclusionUuid": "822CC41D-1864-4A27-9F66-012187A9E33F" }, "name": "visitWithin30Days" }, { "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.", "eMeasureUuids": { "initialPopulationUuid": "2F7B388C-C3BC-4A25-AF3E-E30389970BAC", "denominatorUuid": "2D0AB075-53D3-4183-9809-81E3C69E7A53", "numeratorUuid": "1792D093-5FDD-49E0-BD81-0E31783F35A0", "denominatorExclusionUuid": "D7278999-1937-4CBF-B72F-F359AAD7C97B" }, "name": "visitAndFollowups" } ], "eMeasureUuid": "40280382-68d3-a5fe-0168-e9118c0c0726" }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms159v8", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2020_Measure_MH1_CMSWebInterface_v4.1.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_370_MIPSCQM.pdf" }, "strata": [ { "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.", "eMeasureUuids": { "initialPopulationUuid": "3E189A2F-18C6-4788-80AD-7B6D31977E23", "denominatorUuid": "9374A2BA-D848-4631-BD7F-B9301CB16C6F", "numeratorUuid": "A5976BE6-7F1C-419D-898D-7AFEB141A355", "denominatorExclusionUuid": "368D79F7-DFF9-4987-B870-266C0560A1CE", "strata": [ "4A779584-DBC5-4A07-8E9F-A7502BA537E8", "28EB1666-9599-452B-A722-5FDB1BA72FF4" ] }, "name": "12-17" }, { "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." } ], "eMeasureUuid": "40280382-6963-bf5e-016a-03dca9e446e0" }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms050v8", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_374_MIPSCQM.pdf" }, "eMeasureUuid": "40280382-667f-ecc3-0167-575c0f0447f0", "strata": [ { "description": "Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "E1DD6CEB-0B6C-4842-AB6F-A5578D95CDF6", "denominatorUuid": "82B8DE01-6187-4D29-900A-A14A1EF3D2B7", "numeratorUuid": "DF7F0205-E148-4FAE-82E9-45D72EEB84EC" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms066v8" }, "eMeasureUuid": "40280382-6963-bf5e-0169-e96310694017", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., VR-12, PROMIS-10 Global Health, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA procedure", "eMeasureUuids": { "initialPopulationUuid": "3017D62E-6E32-4D4D-8C0D-3A9573BD788E", "denominatorUuid": "47B4739C-F407-40A2-8BB1-88D759656030", "numeratorUuid": "FE591C1D-132F-46FA-BA47-518E79457B98", "denominatorExclusionUuid": "6C70B6F7-2B61-41CD-A7AF-49B1D2A599C9" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms056v8" }, "eMeasureUuid": "40280382-6963-bf5e-0169-72b83a880718", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., VR-12, PROMIS-10-Global Health, Hip Disability and Osteoarthritis Outcome Score [HOOS], HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 270 - 365 days after the THA procedure", "eMeasureUuids": { "initialPopulationUuid": "5A7BFA25-834D-4C48-AF51-00D95114A421", "denominatorUuid": "A80C742F-D5B3-4C39-8975-2912469D4D24", "numeratorUuid": "7A85EAAD-8EBE-43C0-8783-F1C173522E36", "denominatorExclusionUuid": "69289D3E-3C99-4B41-B6D6-671CB3569999" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms090v9" }, "eMeasureUuid": "40280382-6963-bf5e-0169-7272c0b306be", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; PROMIS -10 Global Health, PROMIS-29) present in the EHR two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial functional status assessment", "eMeasureUuids": { "initialPopulationUuid": "DD08013C-68E3-49EA-9A96-F3DC70558C61", "denominatorUuid": "6D8103B9-95E5-4002-91C6-1365CC5A0C16", "numeratorUuid": "91023EF8-E70C-4080-B4A6-29B0BA5F9A5B", "denominatorExclusionUuid": "5AE96AB3-9901-4BFE-BA70-303E6B35DC96" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms075v8" }, "eMeasureUuid": "40280382-6963-bf5e-0169-b522f1a02370", "strata": [ { "description": "Children who had a diagnosis of cavities or decayed teeth overlapping the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C5875B6A-E68B-4C75-905F-4DE0EE14E452", "denominatorUuid": "F83895DB-4FD9-40DA-B606-420D8402DD02", "numeratorUuid": "3D646A8E-2672-4B25-87E6-7B70645391EE", "denominatorExclusionUuid": "24F0C3EF-2AA4-4F91-96D5-9B3EA445A0C7" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms074v9" }, "eMeasureUuid": "40280382-6963-bf5e-0169-7278084c06db", "strata": [ { "description": "Children who receive a fluoride varnish application during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "FE63B220-546D-4677-BB95-E235125220F6", "denominatorUuid": "489397A5-B24C-4162-B409-7E6A753F6F6A", "numeratorUuid": "CB5FB914-5F42-4B40-B2F5-F238D382999F", "denominatorExclusionUuid": "BCE3A499-3B79-46FA-BD65-9E78295CCB30", "strata": [ "8A4A9149-68EE-487C-806B-2E7F786ABF8F", "127B7D73-FB64-47EF-AC15-58C0B5F11578", "B3F4AF4C-906C-4A6C-89F1-D44C2ECE7CD0" ] } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms177v8" }, "eMeasureUuid": "40280382-6963-bf5e-0169-6dc350b80329", "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "57E186C3-9BA6-4EA0-8ED3-A7B002CE738F", "denominatorUuid": "D02E6B26-38A2-44F9-8532-EDB5B86ADDE5", "numeratorUuid": "AB5AD2BA-F0C8-4C38-8A84-0B57DAB1A6A2" } } ] }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_383_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_384_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_385_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_386_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_387_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_389_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_390_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_391_MIPSCQM.pdf" }, "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_392_MIPSCQM_v4.1.pdf" }, "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_393_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_394_MIPSCQM.pdf" }, "strata": [ { "name": "meningococcal", "description": "Patients who had one dose of meningococcal vaccine on or between the patient�s 11th and 13th birthdays" }, { "name": "Tdap", "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient�s 10th and 13th birthdays" }, { "name": "HPV", "description": "Patients who have completed the HPV vaccine with defferent dates of service on or between the patient's 9th and 13th birthdays" }, { "name": "overall", "description": "All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes" } ] }, { "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "395", "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "College of American Pathologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2020_Measure_395_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_395_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "C34.00", "C34.01", "C34.02", "C34.10", "C34.11", "C34.12", "C34.2", "C34.30", "C34.31", "C34.32", "C34.80", "C34.81", "C34.82", "C34.90", "C34.91", "C34.92" ], "minAge": 18, "procedureCodes": [ { "code": "88104" }, { "code": "88108" }, { "code": "88112" }, { "code": "88173" }, { "code": "88305" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G9418" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9419" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9420" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9421" } ] } ] }, { "title": "Lung Cancer Reporting (Resection Specimens)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "396", "description": "Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.", "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": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2020_Measure_396_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_396_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "C34.00", "C34.01", "C34.02", "C34.10", "C34.11", "C34.12", "C34.2", "C34.30", "C34.31", "C34.32", "C34.80", "C34.81", "C34.82", "C34.90", "C34.91", "C34.92" ], "minAge": 18, "procedureCodes": [ { "code": "88309" } ] } ], "performanceOptions": [ { "optionType": "performanceMet", "qualityCodes": [ { "code": "G9422" } ] }, { "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9423" } ] }, { "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9424" } ] }, { "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9425" } ] } ] }, { "title": "Melanoma Reporting", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "397", "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate.", "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": { "claims": 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"Age Appropriate Screening Colonoscopy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "439", "description": "The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American Gastroenterological Association", "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": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_439_MIPSCQM.pdf" } }, { "title": "Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "440", "description": "Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_440_MIPSCQM.pdf" } }, { "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "441", "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:- Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND- Most recent tobacco status is Tobacco Free -- AND- Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND- Statin Use Unless Contraindicated", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_441_MIPSCQM.pdf" } }, { "title": "Non-Recommended Cervical Cancer Screening in Adolescent Females", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "443", "description": "The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_443_MIPSCQM.pdf" } }, { "title": "Medication Management for People with Asthma", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "444", "description": "The percentage of patients 5-64 years of age during the performance period who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_444_MIPSCQM.pdf" } }, { "title": "Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0119", "measureId": "445", "description": "Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society of Thoracic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_445_MIPSCQM.pdf" } }, { "title": "Appropriate Workup Prior to Endometrial Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "448", "description": "Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_448_MIPSCQM.pdf" } }, { "title": "Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "measureId": "450", "description": "Percentage of female patients (aged 18 years and older) with AJCC stage I (T1c) - III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving Trastuzumab.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "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": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_450_MIPSCQM_v4.1.pdf" } }, { "title": "RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1859", "measureId": "451", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_451_MIPSCQM.pdf" } }, { "title": "Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1860", "measureId": "452", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_452_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0210", "measureId": "453", "description": "Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_453_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0213", "measureId": "455", "description": "Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_455_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureId": "457", "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_457_MIPSCQM.pdf" } }, { "title": "All-cause Hospital Readmission", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1789", "measureId": "458", "description": "The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "primarySteward": "Yale University", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Back Pain After Lumbar Discectomy/Laminectomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "459", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_459_MIPSCQM.pdf" } }, { "title": "Back Pain After Lumbar Fusion", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "460", "description": "For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively.* hereafter referred to as VAS Pain", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_460_MIPSCQM.pdf" } }, { "title": "Leg Pain After Lumbar Discectomy/Laminectomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "461", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS Pain scale at three months (6 to 20 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"Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Oregon Urology Institute", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology", "oncology", "endocrinology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms645v3" }, "eMeasureUuid": "40280382-6963-bf5e-0169-c08817902d03", "strata": [ { "description": "Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment", "eMeasureUuids": { "initialPopulationUuid": "9B77D15F-09B7-4744-9A44-F05769D1D2D8", "denominatorUuid": "869769A6-5A1F-4C0D-8FC0-A8818E7F4F66", "numeratorUuid": "D73B864A-680E-45EF-8082-23A541B4E802", "denominatorExceptionUuid": "0B94B8A9-1294-4CE0-8021-D4B993E3F3F9" } } ] }, { "title": "Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "463", "description": "Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Anesthesiologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_463_MIPSCQM.pdf" } }, { "title": "Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0657", "measureId": "464", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "otolaryngology", "pediatrics", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_464_MIPSCQM.pdf" } }, { "title": "Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "465", "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "Society of Interventional Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_465_MIPSCQM.pdf" } }, { "title": "Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "468", "description": "Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.", "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_468_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_469_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_470_MIPSCQM.pdf" } }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_471_MIPSCQM.pdf" } }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms249v2" }, "eMeasureUuid": "40280382-6963-bf5e-0169-de72aa4339da", "strata": [ { "description": "Female patients who received an order for at least one DXA scan in the measurement period", "eMeasureUuids": { "initialPopulationUuid": "076784AC-D2CA-439F-A802-72D421724A8E", "denominatorUuid": "455FABD1-41BA-40DB-811B-8DB4938D8C59", "numeratorUuid": "05837144-1391-4CE8-810D-FC5629C0B729", "denominatorExclusionUuid": "C06BC21E-7A1B-4CD7-B627-DD1321348271" } } ] }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_473_MIPSCQM.pdf" } }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms349v2" }, "eMeasureUuid": "40280382-6963-bf5e-0169-ca44fb0d3253", "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "EB598957-5695-4CB6-A82C-232A27AEE6B3", "denominatorUuid": "E373ADE6-D02F-49D0-AB0A-C5FBD0FE0B61", "numeratorUuid": "946ECA95-8105-4B1F-B7D1-6FEBFC95551F", "denominatorExclusionUuid": "E0F15B90-8A4D-49B1-9134-2D06D1B0F729" } } ] }, { "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": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2020/cms771v1" }, "eMeasureUuid": "40280382-6963-bf5e-0169-e6713f5a3df1", "strata": [ { "description": "Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C58EED2B-10FB-454A-A3F2-6C8475575868", "denominatorUuid": "F7A05A48-AF98-4849-80A9-E8D6D60430AB", "numeratorUuid": "CFDA6A04-F9A7-44E6-B1F7-310BFCA2791A", "denominatorExclusionUuid": "6948734D-357C-470D-BE2A-13D1A6CD1756" } } ] }, { "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": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_477_MIPSCQM.pdf" } }, { "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. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality. *The Neck FS PROM is an item-response theory-based computer adaptive test (CAT). 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