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"code": "W18.2XXS" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.30XA" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.30XD" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.30XS" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.31XA" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.31XD" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.31XS" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.39XA" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.39XD" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W18.39XS" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W19.XXXA" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W19.XXXD" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "W19.XXXS" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Y92.199" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z59.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z73.6" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.01" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.09" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.1" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.2" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.8" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z74.9" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z91.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z99.11" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z99.3" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z99.81" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "Z99.89" } ] } ] }, { "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS135v9", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureId": "005", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "hospitalists" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms135v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_005_MIPSCQM.pdf" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9895226d00fe", "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": "590BCACE-13CA-4CF8-BDDE-007A35D05A2B", "denominatorUuid": "A56A5A7F-B981-48CC-BFBD-2EB27A294DAD", "numeratorUuid": "D2BE9791-4C01-4403-99EE-6D2B3B1C27F9", "denominatorExceptionUuid": "BFED94C0-70A0-4ECC-8E7E-89996A29AAE7" } }, { "name": "HospitalDischarge", "description": "Patients who were prescribed ACE inhibitor or ARB or ARNI therapy at each hospital discharge", "eMeasureUuids": { "initialPopulationUuid": "97DD6D6F-CE23-4C4A-8AC4-D1479BAE2565", "denominatorUuid": "D0466F55-B262-4060-94FF-14ED1E8D7267", "numeratorUuid": "F1DE987F-3149-4920-B146-E318F7069715", "denominatorExceptionUuid": "AF7AF77C-15CB-496A-BC4E-7F41AF50CC5D" } } ] }, { "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0067", "measureId": "006", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_006_MIPSCQM.pdf" } }, { "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)", "eMeasureId": "CMS145v9", "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": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms145v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_007_MIPSCQM.pdf" }, "eMeasureUuid": "2c928085-7198-38ee-0171-98988f540135", "strata": [ { "name": "LVSD", "description": "Patients with left ventricular systolic dysfunction (LVEF <40%)", "eMeasureUuids": { "initialPopulationUuid": "C8AFA985-2388-41DF-8AE2-05C4BE4E77C9", "denominatorUuid": "13FB25BF-DD03-48D3-8088-03E203EFA540", "numeratorUuid": "D457813A-E76D-4BF8-B653-84B73B355847", "denominatorExceptionUuid": "85E384BB-2C9E-4BEF-B14F-72F3A0C97997" } }, { "name": "priorMI", "description": "Patients with a prior (within the past 3 years) myocardial infarction", "eMeasureUuids": { "initialPopulationUuid": "32D51C08-635E-4CA7-A4C7-960B023BB9AD", "denominatorUuid": "27B59C9C-3B15-4D7C-AFBB-D5CCAA642C19", "numeratorUuid": "60310BDB-A417-49A0-A055-7E5C1C273C01", "denominatorExceptionUuid": "ED454452-BE62-4C4E-A45A-1BF4F79E3933" } } ] }, { "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "eMeasureId": "CMS144v9", "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": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "hospitalists", "skilledNursingFacility" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms144v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_008_MIPSCQM.pdf" }, "eMeasureUuid": "2c928085-7198-38ee-0171-98972d42011e", "strata": [ { "name": "<=12Months", "description": "Patients who were prescribed beta-blocker therapy within a 12-month period when seen in the outpatient setting", "eMeasureUuids": { "initialPopulationUuid": "065E56F2-BC96-4306-9CB3-8D5E727A8EC9", "denominatorUuid": "04025C9A-D1F0-44D0-8214-D8E9E592BD89", "numeratorUuid": "AAB85AF3-3582-4C34-9C36-4339A2DE059C", "denominatorExceptionUuid": "092B3C50-14DA-48DC-985C-A73DA2693793" } }, { "name": "HospitalDischarge", "description": "Patients who were prescribed beta-blocker therapy at each hospital discharge", "eMeasureUuids": { "initialPopulationUuid": "78DA301F-CCF0-452B-BE03-497F9DAC5E7E", "denominatorUuid": "307ACFDF-3ED9-4164-A9DD-2CCC3B84A7A3", "numeratorUuid": "59CA6C03-0C8B-45B7-8E4F-E3BBFD89296F", "denominatorExceptionUuid": "6CED6D74-B23A-4DA1-8677-8C00DD9EE901" } } ] }, { "title": "Anti-Depressant Medication Management", "eMeasureId": "CMS128v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "009", "description": "Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms128v9" }, "strata": [ { "description": "Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).", "eMeasureUuids": { "initialPopulationUuid": "57D85599-15C7-41DB-AA2B-A822DFA3D590", "denominatorUuid": "F8DA7718-407C-4506-A0AC-EAA244583AA3", "numeratorUuid": "73BEC504-0B7D-4EA1-BD42-F1F29BFBBE36", "denominatorExclusionUuid": "11AB50E5-468A-47EA-87F6-7365A68A2695" }, "name": ">=84Days" }, { "description": "Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)", "eMeasureUuids": { "initialPopulationUuid": "867C82CD-4C9C-4366-87C6-2295EF09B1AB", "denominatorUuid": "77F157BE-AF09-478E-ADEB-9F66CE228BC5", "numeratorUuid": "F3B54143-CDFC-4563-B4CA-19169A12252D", "denominatorExclusionUuid": "56391018-F5C8-4D4C-886C-71C36085610C" }, "name": ">=180Days" } ], "eMeasureUuid": "2c928085-7198-38ee-0171-9d7f304f06ee" }, { "title": "Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation", "eMeasureId": "CMS143v9", "nqfEMeasureId": "0086e", "nqfId": "0086", "measureId": "012", "description": "Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms143v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9999e27a042b", "strata": [ { "description": "Patients who have an optic nerve head evaluation during one or more office visits within 12 months", "eMeasureUuids": { "initialPopulationUuid": "A985907B-E233-49E6-B3B3-9DAECFA00563", "denominatorUuid": "0FBAF9DC-C698-42B6-B03C-5AAAF94F2C44", "numeratorUuid": "41AE9BE4-61C3-4548-8FDE-9FDEB00B3808", "denominatorExceptionUuid": "358A7208-4389-4B7C-AE2A-0AFDE1AB8F25" } } ] }, { "title": "Age-Related Macular Degeneration (AMD): Dilated Macular Examination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0087", "measureId": "014", "description": "Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_014_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_014_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "H35.3110", "H35.3111", "H35.3112", "H35.3113", "H35.3114", "H35.3120", "H35.3121", "H35.3122", "H35.3123", "H35.3124", 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This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "orthopedicSurgery", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_024_MedicarePartBClaims.pdf", 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of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "pediatrics", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_205_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Knee Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "217", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_217_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Hip Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "218", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_218_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "219", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_219_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Low Back Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "220", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the FOTO Low Back FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_220_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Shoulder Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "221", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the FOTO Shoulder FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_221_MIPSCQM.pdf" } }, { "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "222", "description": "A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with elbow, wrist, or hand impairments. The change in functional status (FS) is assessed using the FOTO Elbow/Wrist/Hand FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_222_MIPSCQM.pdf" } }, { "title": "Radiology: Reminder System for Screening Mammograms", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0509", "measureId": "225", "description": "Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "structure", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_measure_225_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_225_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "Z12.31" ], "minAge": 0, "optionGroup": "00", "procedureCodes": [ { "code": "77067" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "7025F" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "7025F", "modifiers": [ "1P" ] } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "7025F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "eMeasureId": "CMS138v9", "nqfEMeasureId": "0028e", "nqfId": "0028", "measureId": "226", "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user. Three rates are reported: a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "ophthalmology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "plasticSurgery", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology", "oncology", "rheumatology", "neurosurgical", "podiatry", "physicalTherapyOccupationalTherapy", "urgentCare", "endocrinology", "pulmonology", "clinicalSocialWork", "audiology", "speechLanguagePathology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms138v9", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2021_Measure_PREV10_CMSWebInterface_v5.0.pdf", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_226_MIPSCQM.pdf" }, "strata": [ { "name": "screenedForUse", "description": "Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months", "eMeasureUuids": { "initialPopulationUuid": "FF12FAC1-3D9A-4174-9C05-B313984408DB", "denominatorUuid": "69248984-A61F-4E87-B75B-73EA2EFCE11F", "numeratorUuid": "370D70D8-5872-4742-BE13-F17720FD33B1", "denominatorExceptionUuid": "7D72D403-963E-44DF-8F18-F95A90418C66" } }, { "name": "overall", "description": "Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention", "eMeasureUuids": { "initialPopulationUuid": "AFFE52DA-9272-4F23-9761-45E35ACE8FD0", "denominatorUuid": "D61839FF-8407-4EAD-8D2B-B6C68FDB5D60", "numeratorUuid": "38833BA5-0B98-45C5-9FA3-B01481B5BC53", "denominatorExceptionUuid": "ECC8E00F-60E8-4D0A-81B5-B4AFF39026F9" } }, { "name": "tobacco", "description": "Percentage of patients aged 18 years and older who were screened for 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} ] }, { "optionGroup": "01", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9908" }, { "code": "G9902" } ] }, { "optionGroup": "02", "optionType": "performanceMet", "qualityCodes": [ { "code": "1036F" } ] }, { "optionGroup": "02", "optionType": "performanceMet", "qualityCodes": [ { "code": "4004F" } ] }, { "optionGroup": "02", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9909" } ] }, { "optionGroup": "02", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "4004F", "modifiers": [ "8P" ] } ] }, { "optionGroup": "02", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "4004F", "modifiers": [ "1P" ] } ] } ] }, { "title": "Controlling High Blood Pressure", "eMeasureId": "CMS165v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "236", "description": "Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was 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"optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8753" }, { "code": "G8754" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8755" }, { "code": "G8753" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8756" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8752" }, { "code": "G8755" } ] } ] }, { "title": "Use of High-Risk Medications in Older Adults", "eMeasureId": "CMS156v9", "nqfEMeasureId": null, "nqfId": "0022", "measureId": "238", "description": "Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "internalMedicine", "ophthalmology", "rheumatology", "geriatrics", "skilledNursingFacility", "pulmonology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms156v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_238_MIPSCQM.pdf" }, "strata": [ { "name": "overall", "description": "Percentage of patients who were ordered at least one high-risk medication", "eMeasureUuids": { "initialPopulationUuid": "3E177A28-30DE-4381-8C7A-B42CD914DA33", "denominatorUuid": "E7E1C3BB-730F-4020-9BF3-3AA508B914FC", "numeratorUuid": "14F9E2DB-C09F-4E06-AFBD-C1E5E178D920", "denominatorExclusionUuid": "827502FD-FF19-45FB-974B-B7F32B281873" } } ], "eMeasureUuid": "2c928085-7198-38ee-0171-9d752d1a069e" }, { "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents", "eMeasureId": "CMS155v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "239", "description": "Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.• Percentage of patients with height, weight, and body mass index (BMI) percentile documentation.• Percentage of patients with counseling for nutrition.• Percentage of patients with counseling for physical activity.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "nutritionDietician" ], "measureSpecification": { "electronicHealthRecord": 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"27547B31-B1C5-44A7-B29E-90076761C77A", "7146FA26-F771-48ED-A079-99B5E7F868F2" ] }, "name": "nutrition" }, { "description": "Patients who had counseling for physical activity during a visit that occurs during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "FE1D7F2D-742F-473E-A27B-F032E73B8CC4", "denominatorUuid": "7991ABCD-4420-43BB-924F-EE83042CB3B9", "numeratorUuid": "4C2B1545-7C5F-4D4A-B95E-A79BBA28BAC7", "denominatorExclusionUuid": "6783A696-C02C-40FE-BFDB-94E9EBB03B3D", "strata": [ "CE10198E-5303-4EE8-A924-0078CB258C1E", "8FD1AEF2-5112-47CC-A854-5194000091EB" ] }, "name": "physicalActivity" } ], "eMeasureUuid": "2c928085-7198-38ee-0171-9da0c2cd078a" }, { "title": "Childhood Immunization Status", "eMeasureId": "CMS117v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "240", "description": "Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms117v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9d6e75580676", "strata": [ { "description": "Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday", "eMeasureUuids": { "initialPopulationUuid": "C250C33A-DB0C-4BCA-B960-1C4233F43F4B", "denominatorUuid": "6CC68F62-3E17-4A10-8612-5496F0D42E85", "numeratorUuid": "74914562-4904-47EB-84D4-72C25964B5B0", "denominatorExclusionUuid": "4556ED56-B7FF-47F5-A84E-B3916BA13EB2" } } ] }, { "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0643", "measureId": "243", "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Heart Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_243_MIPSCQM.pdf" } }, { "title": "Barrett’s Esophagus", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1854", "measureId": "249", "description": "Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "College of American Pathologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_249_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_249_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "K22.70", "K22.710", "K22.711", "K22.719" ], "minAge": 0, "optionGroup": "00", "procedureCodes": [ { "code": "88305" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G8797" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "3126F" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "3126F", "modifiers": [ "1P" ] } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3126F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Radical Prostatectomy Pathology Reporting", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1853", "measureId": "250", "description": "Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "College of American Pathologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology", "oncology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_250_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_250_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "C61" ], "minAge": 0, "optionGroup": "00", "procedureCodes": [ { "code": "88309" } ], "sexCode": "M" } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G8798" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "3267F" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "3267F", "modifiers": [ "1P" ] } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "3267F", "modifiers": [ "8P" ] } ] } ] }, { "title": "Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "254", "description": "Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American College of Emergency Physicians", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_254_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_254_MIPSCQM.pdf" }, "eligibilityOptions": [ { "additionalDiagnosisCodes": [ "R10.0", "R10.10", "R10.13", "R10.2", "R10.30", "R10.31", "R10.32", "R10.33", "R10.813", "R10.814", "R10.815", "R10.816", "R10.817", "R10.819", "R10.823", "R10.824", "R10.825", "R10.826", "R10.827", "R10.829", "R10.84", "R10.9" ], "diagnosisCodes": [ "O26.891", "O26.899", "O26.90", "O26.91" ], "maxAge": 50, "minAge": 14, "optionGroup": "00", "procedureCodes": [ { "code": "99281", "placesOfService": [ "23" ] }, { "code": "99282", "placesOfService": [ "23" ] }, { "code": "99283", "placesOfService": [ "23" ] }, { "code": "99284", "placesOfService": [ "23" ] }, { "code": "99285", "placesOfService": [ "23" ] }, { "code": "99291", "placesOfService": [ "23" ] } ], "sexCode": "F" }, { "additionalDiagnosisCodes": [ "O20.0", "O20.8", "O20.9", "O44.30", "O44.31", "O44.50", "O44.51", "O45.001", "O45.009", "O45.011", "O45.019", "O45.021", "O45.029", "O45.091", "O45.099", "O45.8X1", "O45.8X9", "O45.90", "O45.91", "O46.001", "O46.009", "O46.011", "O46.019", "O46.021", "O46.029", "O46.091", "O46.099", "O46.8X1", "O46.8X9", "O46.90", "O46.91" ], "diagnosisCodes": [ "O26.891", "O26.899", "O26.90", "O26.91" ], "maxAge": 50, "minAge": 14, "optionGroup": "00", "procedureCodes": [ { "code": "99281", "placesOfService": [ "23" ] }, { "code": "99282", "placesOfService": [ "23" ] }, { "code": "99283", "placesOfService": [ "23" ] }, { "code": "99284", "placesOfService": [ "23" ] }, { "code": "99285", "placesOfService": [ "23" ] }, { "code": "99291", "placesOfService": [ "23" ] } ], "sexCode": "F" } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8807" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8806" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8808" } ] } ] }, { "title": "Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "258", "description": "Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms (AAA) who do not experience a major complication (discharge to home no later than post-operative day #7).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_258_MIPSCQM.pdf" } }, { "title": "Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "259", "description": "Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_259_MIPSCQM.pdf" } }, { "title": "Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "260", "description": "Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) who are discharged to home no later than post-operative day #2.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Society for Vascular Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_260_MIPSCQM.pdf" } }, { "title": "Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "261", "description": "Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Audiology Quality Consortium", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "audiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_measure_261_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_261_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "H81.10", "H81.11", "H81.12", "H81.13", "R42" ], "minAge": 0, "optionGroup": "00", "procedureCodes": [ { "code": "92540" }, { "code": "92541" }, { "code": "92542" }, { "code": "92544" }, { "code": "92545" }, { "code": "92546" }, { "code": "92548" }, { "code": "92550" }, { "code": "92557" }, { "code": "92567" }, { "code": "92568" }, { "code": "92570" }, { "code": "92575" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G8857" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G8856" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G8858" } ] } ] }, { "title": "Sentinel Lymph Node Biopsy for Invasive Breast Cancer", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "264", "description": "The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Breast Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_264_MIPSCQM.pdf" } }, { "title": "Biopsy Follow-Up", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "265", "description": "Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "obstetricsGynecology", "otolaryngology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_265_MIPSCQM.pdf" } }, { "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "268", "description": "Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_268_MIPSCQM.pdf" } }, { "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "275", "description": "Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_275_mipscqm.pdf" } }, { "title": "Sleep Apnea: Severity Assessment at Initial Diagnosis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "277", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "otolaryngology", "neurology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_277_MIPSCQM.pdf" } }, { "title": "Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "279", "description": "Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Sleep Medicine", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "otolaryngology", "neurology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_279_MIPSCQM.pdf" } }, { "title": "Dementia: Cognitive Assessment", "eMeasureId": "CMS149v9", "nqfEMeasureId": "2872e", "nqfId": null, "measureId": "281", "description": "Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms149v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-98a9d3bf017a", "strata": [ { "description": "Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period", "eMeasureUuids": { "initialPopulationUuid": "FA642DFE-1C0D-4724-9538-B0F199C9CEFD", "denominatorUuid": "115AD8E4-8FC1-484C-8F7A-426DEEFD989F", "numeratorUuid": "6621BE4E-4E50-46A6-8952-E9AE5B45540B", "denominatorExceptionUuid": "C4504094-168D-437D-B8AB-7C28DC3D1FB7" } } ] }, { "title": "Dementia: Functional Status Assessment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "282", "description": "Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology/American Psychiatric Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "geriatrics", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_282_MIPSCQM.pdf" } }, { "title": "Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "283", "description": "Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology/American Psychiatric Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_283_MIPSCQM.pdf" } }, { "title": "Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "286", "description": "Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Academy of Neurology/American Psychiatric Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_286_MIPSCQM.pdf" } }, { "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "288", "description": "Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology/American Psychiatric Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy", "geriatrics", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_288_MIPSCQM.pdf" } }, { "title": "Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "290", "description": "Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms once in the past 12 months", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_290_MIPSCQM.pdf" } }, { "title": "Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "291", "description": "Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once in the past 12 months.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_291_MIPSCQM.pdf" } }, { "title": "Parkinson’s Disease: Rehabilitative Therapy Options", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "293", "description": "Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed once in the past 12 months.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Academy of Neurology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_293_MIPSCQM.pdf" } }, { "title": "Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "303", "description": "Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_303_MIPSCQM.pdf" } }, { "title": "Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "304", "description": "Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientEngagementExperience", "primarySteward": "American Academy of Ophthalmology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_304_MIPSCQM.pdf" } }, { "title": "Initiation and Engagement of Alcohol and Other Drug Dependence Treatment", "eMeasureId": "CMS137v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "305", "description": "Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis.b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "simpleAverage", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms137v9" }, "strata": [ { "description": "Patients who initiated treatment within 14 days of the diagnosis", "eMeasureUuids": { "initialPopulationUuid": "0D7EB2C8-A8C7-406E-9F6F-961C85CB5791", "denominatorUuid": "3A93FF10-3E3A-47E4-9D97-EFB6B6241BE1", "numeratorUuid": "F2EC55BA-4652-4705-84DC-6AC184A5C4C1", "denominatorExclusionUuid": "00DAA49B-10E5-4E02-A9B9-20911A88C14A", "strata": [ "C447FBC7-B826-4CE1-A23C-4932EAE2A587", "B9348806-52DD-415D-9496-EA21566DFD21" ] }, "name": "14DaysOfDiagnosis" }, { "description": "Patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit", "eMeasureUuids": { "initialPopulationUuid": "13982B0A-1AE1-48AD-A1C7-6A7CA3A8ECD6", "denominatorUuid": "9092B765-3F9C-4067-9695-673B7A0AA818", "numeratorUuid": "6B89D395-0750-4DB2-BAAF-6ADBBE802592", "denominatorExclusionUuid": "36BE31B3-B355-42DA-ACC9-75EFF0A0F553", "strata": [ "598BEF83-C10C-4A99-95F1-85B66842C4BC", "06E5DF8B-6BAD-4F9C-9F6D-A653F4B0208A" ] }, "name": "30DaysOfVisit" } ], "eMeasureUuid": "2c928085-7198-38ee-0171-9d81b6570705" }, { "title": "Cervical Cancer Screening", "eMeasureId": "CMS124v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "309", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed within the last 3 years* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms124v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9d8c44fe0746", "strata": [ { "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:\n* Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test\n\n* Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test", "eMeasureUuids": { "initialPopulationUuid": "ECFD977D-D1A2-487B-8033-CC9E61B5B5F7", "denominatorUuid": "C373C463-77DF-4C19-80E0-2A344BD3FEA2", "numeratorUuid": "7502090C-3073-419F-8A76-63CEF417107B", "denominatorExclusionUuid": "1F694042-1951-404A-B0CB-92527C9505CB" } } ] }, { "title": "Chlamydia Screening for Women", "eMeasureId": "CMS153v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "310", "description": "Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the 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"qualityCodes": [ { "code": "G8967" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9928" } ] } ] }, { "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "331", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_331_MIPSCQM.pdf" } }, { "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "332", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_332_MIPSCQM.pdf" } }, { "title": "Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "335", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries by cesarean section (C-section), or early inductions of labor, without medical indication.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_335_MIPSCQM.pdf" } }, { "title": "Maternity Care: Postpartum Follow-up and Care Coordination", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "336", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 8 weeks of giving birth and received the following at the postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_336_MIPSCQM.pdf" } }, { "title": "Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "337", "description": "Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Academy of Dermatology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_337_MIPSCQM.pdf" } }, { "title": "HIV Viral Load Suppression", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2082", "measureId": "338", "description": "The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Health Resources and Services Administration", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_338_MIPSCQM.pdf" } }, { "title": "HIV Medical Visit Frequency", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2079", "measureId": "340", "description": "Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "Health Resources and Services Administration", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "infectiousDisease" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_340_MIPSCQM.pdf" } }, { "title": "Pain Brought Under Control Within 48 Hours", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0209", "measureId": "342", "description": "Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "outcome", "primarySteward": "National Hospice and Palliative Care Organization", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_342_MIPSCQM.pdf" } }, { "title": "Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "344", "description": "Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society for Vascular Surgery", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "vascularSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_344_MIPSCQM.pdf" } }, { "title": "Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "350", "description": "Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "American Association of Hip and Knee Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "plasticSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "otolaryngology", "plasticSurgery", "vascularSurgery", "generalSurgery", "thoracicSurgery", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_360.zip" } }, { "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_364_MIPSCQM.pdf" } }, { "title": "Follow-Up Care for Children Prescribed ADHD Medication (ADD)", "eMeasureId": "CMS136v10", "nqfEMeasureId": null, "nqfId": null, "measureId": "366", "description": "Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a) Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.b) Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.", "nationalQualityStrategyDomain": "Effective Clinical Care", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms136v10" }, "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": "258C7C5D-33A9-4344-8D26-D35CE7FD11FF", "denominatorUuid": "2D031600-3FF7-43FB-8D07-56D05DFB1092", "numeratorUuid": "91F1B47D-8357-4D1F-982C-F1CA45EA80B2", "denominatorExclusionUuid": "EF583993-6453-4B51-97B3-84FAF366B3F6" }, "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": "6FFE774B-CFA8-481E-B201-1CFC738E4685", "denominatorUuid": "0F80BF70-B407-4E09-9803-3AAB15CA9E14", "numeratorUuid": "A823E7C1-8B1E-4A75-AFF2-BF4946F8980D", "denominatorExclusionUuid": "7705EDA2-8A0B-4E3F-A83B-483B5F9BD87A" }, "name": "visitAndFollowups" } ], "eMeasureUuid": "2c928085-7198-38ee-0171-9dab7a4b07c4" }, { "title": "Depression Remission at Twelve Months", "eMeasureId": "CMS159v9", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "pediatrics", "mentalBehavioralHealth", "geriatrics", "clinicalSocialWork" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms159v9", "cmsWebInterface": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Web-Interface-Measures/2021_Measure_MH1_CMSWebInterface_v5.0.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_370_MIPSCQM.pdf" }, "strata": [ { "description": "Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an\ninitial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve\nmonths as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5.", "eMeasureUuids": { "initialPopulationUuid": "BBB0D5FB-58B3-4F52-B34B-FE1FA70FA37A", "denominatorUuid": "ABA073DB-F22A-40DF-85BA-D4C817E9DA42", "numeratorUuid": "779282B6-7FFE-4261-A979-833C6D7E9BD5", "denominatorExclusionUuid": "51BDFCA5-362F-429A-A776-5FC9A2E0EFC1" }, "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\ninitial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve\nmonths as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5." } ], "eMeasureUuid": "2c928085-7198-38ee-0171-9e951ae1097e" }, { "title": "Closing the Referral Loop: Receipt of Specialist Report", "eMeasureId": "CMS50v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "374", "description": "Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "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/2021/cms050v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_374_MIPSCQM.pdf" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9983f7b003c1", "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": "84909538-B21D-4FEF-A39A-5B6CD8E5ABF6", "denominatorUuid": "E2423A7C-4CDC-4AC3-9A62-C5A42AA6EC90", "numeratorUuid": "D88B2BC2-B510-448B-AD39-EC0424E0A5B2" } } ] }, { "title": "Functional Status Assessment for Total Knee Replacement", "eMeasureId": "CMS66v9", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms066v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9d4b226a05d0", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [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": "07F00615-05B2-4CB4-AD59-EC4800002403", "denominatorUuid": "6C43F178-73B0-4492-8F87-05CDE817D19A", "numeratorUuid": "BF424716-C760-4911-B3EA-3D359C2B8634", "denominatorExclusionUuid": "0EF25614-4C56-4E77-A2FC-120D57E92D78" } } ] }, { "title": "Functional Status Assessment for Total Hip Replacement", "eMeasureId": "CMS56v9", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms056v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9d3ba3b30572", "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [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": "688AFBFB-1F6B-4C19-8DF5-DEE620488A63", "denominatorUuid": "F03E5B4A-29F5-4126-B6D2-149F2301F99B", "numeratorUuid": "CE0EDD99-1953-4E2D-BD17-53B3125A7220", "denominatorExclusionUuid": "0D631113-333A-4177-8228-895337056ACD" } } ] }, { "title": "Functional Status Assessments for Congestive Heart Failure", "eMeasureId": "CMS90v10", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms090v10" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9e6fc13d08f2", "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]; Patient-Reported Outcomes Measurement Information System [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 FSA", "eMeasureUuids": { "initialPopulationUuid": "4BB978B2-C988-444B-A11B-82FF49D2DA33", "denominatorUuid": "FB611C04-1B03-44CF-9520-BFD5DDC546E7", "numeratorUuid": "5AF174D3-3FCC-4081-8102-01ADDEE7C0AA", "denominatorExclusionUuid": "0F338C02-C66E-4F3C-AB8B-2C44B9C2392C" } } ] }, { "title": "Children Who Have Dental Decay or Cavities", "eMeasureId": "CMS75v9", "nqfEMeasureId": null, "nqfId": null, "measureId": "378", "description": "Percentage of children, 6 months - 20 years of age, 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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms075v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9d56875005f8", "strata": [ { "description": "Children who had a diagnosis of cavities or decayed teeth overlapping the measurement period", "eMeasureUuids": { "initialPopulationUuid": "78E06F92-E035-4AFC-9290-33CD6F0F6E1F", "denominatorUuid": "8DFABFF0-A1E4-432F-960B-E3AAB8738F76", "numeratorUuid": "BDEF3B51-CBFD-4425-8772-35B4F5927E4F", "denominatorExclusionUuid": "4C15ACA6-8FCE-4328-8441-4B1AA7521949" } } ] }, { "title": "Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists", "eMeasureId": "CMS74v10", "nqfEMeasureId": null, "nqfId": null, "measureId": "379", "description": "Percentage of children, 6 months - 20 years of age, 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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms074v10" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9d602fc3061a", "strata": [ { "description": "Children who receive a fluoride varnish application during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "98E4F56E-2A4A-43CF-B89B-E5DC8E9A1348", "denominatorUuid": "D630F0DC-A7DD-4DE5-8F8A-43C6C9F0BD6D", "numeratorUuid": "3920E2F1-A3D1-4C0B-829A-AA5EB1BDD46A", "denominatorExclusionUuid": "2F2944A9-C372-4347-B19C-BD4C3BBC81BB", "strata": [ "F06F7349-B75E-450A-854E-B93A3119A545", "BC21022F-7A08-4AA4-A53C-689BA51D1378", "51E2DEC7-217A-436E-B27F-BC2DA9384534" ] } } ] }, { "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "eMeasureId": "CMS177v9", "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": "Mathematica", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "pediatrics", "mentalBehavioralHealth", "clinicalSocialWork" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms177v9" }, "eMeasureUuid": "2c928085-7198-38ee-0171-98abf9c0019d", "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "0F2BD817-7BC3-41FA-90F9-C85AE36CA859", "denominatorUuid": "7B01C86F-68C7-4D7F-88CC-5377C869AE52", "numeratorUuid": "D01E6E8D-D6CD-40EC-BC02-E709AA53996A" } } ] }, { "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 performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.", "nationalQualityStrategyDomain": "Patient Safety", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_389_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "pediatrics", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_392_MIPSCQM.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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_393_MIPSCQM.pdf" } }, { "title": "Immunizations for Adolescents", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "394", "description": "The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.", "nationalQualityStrategyDomain": "Community/Population Health", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "pediatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_394_MIPSCQM.pdf" }, "strata": [ { "name": "meningococcal", "description": "Patients who had one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays" }, { "name": "Tdap", "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient's 10th and 13th birthdays" }, { "name": "HPV", "description": "Patients who have completed the HPV vaccine with defferent dates of service on or between the patient's 9th and 13th birthdays" }, { "name": "overall", "description": "All patients who are compliant for Meningococcal, Tdap and HPV during the specified timeframes" } ] }, { "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "395", "description": "Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "College of American Pathologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_395_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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, "optionGroup": "00", "procedureCodes": [ { "code": "88104" }, { "code": "88108" }, { "code": "88112" }, { "code": "88173" }, { "code": "88305" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9418" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9419" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9420" } ] }, { "optionGroup": "00", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_396_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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, "optionGroup": "00", "procedureCodes": [ { "code": "88309" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9422" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9423" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9424" } ] }, { "optionGroup": "00", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_397_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_397_MIPSCQM.pdf" }, "eligibilityOptions": [ { "diagnosisCodes": [ "C43.0", "C43.20", "C43.21", "C43.22", "C43.30", "C43.31", "C43.39", "C43.4", "C43.51", "C43.52", "C43.59", "C43.60", "C43.61", "C43.62", "C43.70", "C43.71", "C43.72", "C43.8", "C43.9" ], "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "88305" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9428" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9429" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9430" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9431" } ] } ] }, { "title": "Optimal Asthma Control", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "398", "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Minnesota Community Measurement", "metricType": "multiPerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "overallAlgorithm": "overallStratumOnly", "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "otolaryngology", "pediatrics", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_398_MIPSCQM.pdf" }, "strata": [ { "name": "overall", "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "5-17", "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation." }, { "name": "18-50", "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "ACT5-17", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma" }, { "name": "ACT18-50", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma" }, { "name": "lowRisk5-17", "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma" }, { "name": "lowRisk18-50", "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma" } ] }, { "title": "One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "400", "description": "Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_400_MIPSCQM.pdf" } }, { "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "401", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology", "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_401_mipscqm.pdf" } }, { "title": "Tobacco Use and Help with Quitting Among Adolescents", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2803", "measureId": "402", "description": "The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "gastroenterology", "dermatology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "vascularSurgery", "generalSurgery", "thoracicSurgery", "oncology", "rheumatology", "urgentCare", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_402_MIPSCQM.pdf" } }, { "title": "Anesthesiology Smoking Abstinence", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "404", "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "intermediateOutcome", "primarySteward": "American Society of Anesthesiologists", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_404_MIPSCQM.pdf" } }, { "title": "Appropriate Follow-up Imaging for Incidental Abdominal Lesions", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "405", "description": "Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow‐up imaging recommended based on radiological findings:• Cystic renal lesion that is simple appearing* (Bosniak I or II)• Adrenal lesion less than or equal to 1.0 cm• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols", "nationalQualityStrategyDomain": "Effective Clinical Care", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_Measure_405_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_405_MIPSCQM.zip" }, "eligibilityOptions": [ { "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "71250" }, { "code": "71260" }, { "code": "71270" }, { "code": "71275" }, { "code": "71555" }, { "code": "72131" }, { "code": "72191" }, { "code": "72192" }, { "code": "72193" }, { "code": "72194" }, { "code": "72195" }, { "code": "72196" }, { "code": "72197" }, { "code": "72198" }, { "code": "74150" }, { "code": "74160" }, { "code": "74170" }, { "code": "74176" }, { "code": "74177" }, { "code": "74178" }, { "code": "74181" }, { "code": "74182" }, { "code": "74183" }, { "code": "G0297" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9549" }, { "code": "G9547" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9550" }, { "code": "G9547" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9551" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9547" }, { "code": "G9548" } ] } ] }, { "title": "Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "406", "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American College of Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_measure_406_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_406_MIPSCQM.pdf" }, "eligibilityOptions": [ { "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "70486" }, { "code": "70487" }, { "code": "70488" }, { "code": "70490" }, { "code": "70491" }, { "code": "70492" }, { "code": "70498" }, { "code": "70540" }, { "code": "70542" }, { "code": "70543" }, { "code": "70547" }, { "code": "70548" }, { "code": "70549" }, { "code": "71250" }, { "code": "71260" }, { "code": "71270" }, { "code": "71271" }, { "code": "71550" }, { "code": "71551" }, { "code": "71552" }, { "code": "71555" }, { "code": "72125" }, { "code": "72126" }, { "code": "72127" }, { "code": "72141" }, { "code": "72142" }, { "code": "72156" } ] } ], "performanceOptions": [ { "optionGroup": "00", "optionType": "eligiblePopulationException", "qualityCodes": [ { "code": "G9555" }, { "code": "G9552" } ] }, { "optionGroup": "00", "optionType": "eligiblePopulationExclusion", "qualityCodes": [ { "code": "G9557" } ] }, { "optionGroup": "00", "optionType": "performanceMet", "qualityCodes": [ { "code": "G9552" }, { "code": "G9554" } ] }, { "optionGroup": "00", "optionType": "performanceNotMet", "qualityCodes": [ { "code": "G9556" }, { "code": "G9552" } ] } ] }, { "title": "Clinical Outcome Post Endovascular Stroke Treatment", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "409", "description": "Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society of Interventional Radiology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, 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"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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "gastroenterology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "otolaryngology", "physicalMedicine", "preventiveMedicine", "neurology", "mentalBehavioralHealth", "urology", "oncology", "urgentCare", "nutritionDietician", "pulmonology", "clinicalSocialWork" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_431_MIPSCQM.pdf" }, 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false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2021_measure_436_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_436_MIPSCQM.pdf" }, "eligibilityOptions": [ { "minAge": 18, "optionGroup": "00", "procedureCodes": [ { "code": "70450" }, { "code": "70460" }, { "code": "70470" }, { "code": "70480" }, { "code": "70481" }, { "code": "70482" }, { "code": "70486" }, { "code": "70487" }, { "code": "70488" }, { "code": "70490" }, { "code": "70491" }, { "code": "70492" }, { "code": "70496" }, { "code": "70498" }, { "code": "71250" }, { "code": "71260" }, { "code": "71270" }, { "code": "71271" }, { "code": "71275" }, { "code": "72125" }, { "code": "72126" }, { "code": "72127" }, { "code": "72128" }, { "code": "72129" }, { "code": "72130" }, { "code": "72131" }, { "code": "72132" }, { "code": "72133" }, { "code": "72191" }, { "code": "72192" }, { "code": "72193" }, { "code": "72194" }, { "code": "73200" }, { "code": "73201" }, { "code": "73202" }, { "code": "73206" }, { "code": "73700" }, { "code": "73701" }, { "code": "73702" }, { "code": "73706" }, { "code": "74150" }, { "code": "74160" }, { "code": "74170" }, { "code": "74174" }, { "code": "74175" }, { "code": "74176" }, { "code": "74177" }, { "code": "74178" }, { "code": "74261" }, { "code": "74262" }, { "code": "74263" }, { "code": "75571" }, { "code": "75572" }, { "code": "75573" }, { "code": "75574" }, { "code": "75635" }, { "code": "76380" }, { "code": "76497" }, { "code": "77011" }, { "code": "77012" }, { "code": "77013" }, { "code": "77014" }, { "code": "77078" }, { "code": "0042T" }, { "code": 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OR• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": false, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord", "cmsWebInterface", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "preventiveMedicine", "endocrinology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms347v4", "cmsWebInterface": 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(LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia", "eMeasureUuids": { "initialPopulationUuid": "164ECE60-97E5-4F72-8FE1-D1C62E04D174", "denominatorUuid": "DA3E9773-E6F9-415E-B6DF-9DFDAB829D91", "numeratorUuid": "BABDCD3E-75C1-40A5-8527-C9EBDDBB5E55", "denominatorExclusionUuid": "01B500BB-4556-4CF4-9676-28FA2392147C", "denominatorExceptionUuid": "84CD03D9-6BAA-4C56-9205-2F5A22CBDEE6" } }, { "name": "between40And75", "description": "Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL", "eMeasureUuids": { "initialPopulationUuid": "44D2CD88-3F1C-4908-AFA7-5EB3D2B46F79", "denominatorUuid": "1A916B14-DA81-4CBD-AA50-78CBFDEC7BD4", "numeratorUuid": "EA99DDF7-D7D0-4B83-BA2C-9DA99548055C", "denominatorExclusionUuid": "0EAEA873-BD9C-4CF8-9989-BB138F2BDFE5", "denominatorExceptionUuid": "120861DA-61F1-48CC-BA99-27EE9073D896" } } ] }, { "title": "Age Appropriate Screening Colonoscopy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "439", "description": "The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "efficiency", "primarySteward": "American Gastroenterological Association", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_441_MIPSCQM.pdf" } }, { "title": "Non-Recommended Cervical Cancer Screening in Adolescent Females", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "443", "description": "The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_443_MIPSCQM.pdf" } }, { "title": "Medication Management for People with Asthma", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "444", "description": "The percentage of patients 5-64 years of age during the performance period who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period.", "nationalQualityStrategyDomain": "Efficiency and Cost Reduction", "measureType": "process", "primarySteward": "National Committee for Quality Assurance", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "pediatrics", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_444_MIPSCQM.pdf" } }, { "title": "Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0119", "measureId": "445", "description": "Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "Society of Thoracic Surgeons", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_measure_445_MIPSCQM.pdf" } }, { "title": "Appropriate Workup Prior to Endometrial Ablation", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "448", "description": "Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "process", "primarySteward": "Centers for Medicare & Medicaid Services", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_448_MIPSCQM.pdf" } }, { "title": "Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "measureId": "450", "description": "Percentage of female patients aged 18 to 70 with stage I (T1c) - III HER2 positive breast cancer for whom appropriate treatment is initiated.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_450_MIPSCQM.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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_451_MIPSCQM.pdf" } }, { "title": "Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1860", "measureId": "452", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_452_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0210", "measureId": "453", "description": "Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "process", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "geriatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_455_MIPSCQM.pdf" } }, { "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureId": "457", "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.", "nationalQualityStrategyDomain": "Effective Clinical Care", "measureType": "outcome", "primarySteward": "American Society of Clinical Oncology", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_457_MIPSCQM.pdf" } }, { "title": "Back Pain After Lumbar Discectomy/Laminectomy", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "459", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_459_MIPSCQM.pdf" } }, { "title": "Back Pain After Lumbar Fusion", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "460", "description": "For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively.* hereafter referred to as VAS Pain", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Minnesota Community Measurement", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_460_MIPSCQM.pdf" } }, { "title": "Leg Pain After Lumbar Discectomy/Laminectomy", "eMeasureId": null, "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 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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_461_MIPSCQM.pdf" } }, { "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "eMeasureId": "CMS645v4", "nqfEMeasureId": null, "nqfId": null, "measureId": "462", "description": "Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.", "nationalQualityStrategyDomain": "Effective Clinical Care", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology", "oncology", "endocrinology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms645v4" }, "eMeasureUuid": "2c928085-7198-38ee-0171-991e164e0307", "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": "52F12771-64AC-4236-88D1-5780F5709BE8", "denominatorUuid": "74889BF4-21BB-4F5A-BD12-3707FA6F0063", "numeratorUuid": "244CFA99-6642-431B-9335-15BAD232C9D2", "denominatorExceptionUuid": "FF123268-78C8-4439-8CD0-B3A0003497D6" } } ] }, { "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "otolaryngology", "pediatrics", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_464_MIPSCQM.pdf" } }, { "title": "Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "465", "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.", "nationalQualityStrategyDomain": "Patient Safety", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "physicalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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.* hereafter referred to as ODI", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.", "nationalQualityStrategyDomain": "Person and Caregiver-Centered Experience and Outcomes", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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.* hereafter referred to as ODI", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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": "CMS249v3", "nqfEMeasureId": "3475e", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms249v3" }, "eMeasureUuid": "2c928085-7198-38ee-0171-9876b21e0093", "strata": [ { "description": "Female patients who received an order for at least one DXA scan in the measurement period", "eMeasureUuids": { "initialPopulationUuid": "F0A68A1B-0261-411C-BE9E-9AFCDA263676", "denominatorUuid": "5676A192-5602-44B5-886A-23A045008F0F", "numeratorUuid": "906BE36C-F868-4A84-9C5F-75D2A259801C", "denominatorExclusionUuid": "634D7208-01BE-40B0-AAD9-27DC6ED13395" } } ] }, { "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_473_MIPSCQM.pdf" } }, { "title": "HIV Screening", "eMeasureId": "CMS349v3", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "infectiousDisease" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms349v3" }, "eMeasureUuid": "2c928085-7198-38ee-0171-98e8f5530275", "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "121D9C35-175C-4768-930C-CE4681DB7988", "denominatorUuid": "E61633B7-37B5-430A-9890-CF4F9E659096", "numeratorUuid": "77F4ABB1-BA6B-4C29-85FE-C6A8E570C59B", "denominatorExclusionUuid": "5B47F56E-B8F7-4830-82E7-602D11E27262" } } ] }, { "title": "Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia", "eMeasureId": "CMS771v2", "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology", "geriatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ep/2021/cms771v2" }, "eMeasureUuid": "2c928085-7198-38ee-0171-996032910386", "strata": [ { "description": "Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "245B975E-C587-407F-9B57-81ABB16DF313", "denominatorUuid": "11A690EA-0BCD-4249-984F-F9A15752F8FC", "numeratorUuid": "1FB963C1-ED0D-403F-A117-4371F5BFB3FE", "denominatorExclusionUuid": "FBF8B98B-A767-433C-9957-DFCA8DAEC1C9" } } ] }, { "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": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_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 measure of risk-adjusted change in functional status for patients aged 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paper-pencil).", "nationalQualityStrategyDomain": "Person and Caregiver-centered Experience and Outcomes", "measureType": "patientReportedOutcome", "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "metricType": "singlePerformanceRate", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": false, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "cpcPlus", "pcf" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "chiropracticMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2021_Measure_478_MIPSCQM.pdf" } }, { "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "479", "description": "This measure is a re-specified version of the measure, “Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition” (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group’s readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "nationalQualityStrategyDomain": "Communication and Care Coordination", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services (CMS)", "metricType": "costScore", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "app1" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3493", "measureId": "480", "description": "This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.", "nationalQualityStrategyDomain": "Patient Safety", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services (CMS)", "metricType": "costScore", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} }, { "title": "All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)", "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureId": "MCC1", "description": "Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service (FFS) beneficiaries 65 years and older with multiple chronic conditions (MCCs) who are assigned to the Accountable Care Organization (ACO)", "nationalQualityStrategyDomain": "Outcome", "measureType": "outcome", "primarySteward": "Centers for Medicare & Medicaid Services (CMS)", "metricType": "costScore", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isHighPriority": true, "isInverse": true, "isIcdImpacted": false, "isClinicalGuidelineChanged": false, "category": "quality", "isRegistryMeasure": false, "isRiskAdjusted": false, "icdImpacted": [], "clinicalGuidelineChanged": [], "allowedPrograms": [ "app1" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": {} } ]