Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
Quality ID
93
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Pediatrics, Urgent Care
Primary Measure Steward
American Academy of Otolaryngology – Head and Neck Surgery
Acute Otitis Externa (AOE): Topical Therapy
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations
Quality ID
91
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Pediatrics, Urgent Care
Primary Measure Steward
American Academy of Otolaryngology – Head and Neck Surgery
Adherence to Antipsychotic Medications For Individuals with Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)
Quality ID
383
NQS Domain
Patient Safety
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Mental/Behavioral Health
Primary Measure Steward
Health Services Advisory Group
Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
Quality ID
329
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
Renal Physicians Association
Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter
Quality ID
330
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Nephrology
Primary Measure Steward
Renal Physicians Association
Adult Kidney Disease: Referral to Hospice
Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care
Quality ID
403
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Nephrology
Primary Measure Steward
Renal Physicians Association
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
Quality ID
325
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Mental/Behavioral Health
Primary Measure Steward
American Psychiatric Association
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
Quality ID
107
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Emergency Medicine, Family Medicine, Mental/Behavioral Health
Primary Measure Steward
Physician Consortium for Performance Improvement
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery
Quality ID
384
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye
Quality ID
385
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
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
Quality ID
331
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Urgent Care
Primary Measure Steward
American Academy of Otolaryngology – Head and Neck Surgery
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis
Quality ID
332
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Urgent Care
Primary Measure Steward
American Academy of Otolaryngology – Head and Neck Surgery
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
Quality ID
333
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Urgent Care
Primary Measure Steward
American Academy of Otolaryngology – Head and Neck Surgery
Advance Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
Quality ID
47
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Cardiology, Gastroenterology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventive Medicine, Neurology, Vascular Surgery, General Surgery, Thoracic Surgery, Urology, Oncology, Hospitalists, Rheumatology, Nephrology, Geriatrics, Skilled Nursing Facility
Primary Measure Steward
National Committee for Quality Assurance
Age Appropriate Screening Colonoscopy
The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31
Quality ID
439
NQS Domain
Effective Clinical Care
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period
Quality ID
14
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
All-cause Hospital Readmission
The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge
Quality ID
458
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Administrative Claims
Specialty Measure Set
n/a
Primary Measure Steward
Yale University
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually
Quality ID
386
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Anastomotic Leak Intervention
Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery
Quality ID
354
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
American College of Surgeons
Anesthesiology Smoking Abstinence
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure
Quality ID
404
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period
Quality ID
387
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Anti-Depressant Medication Management
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)
Quality ID
9
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Mental/Behavioral Health
Primary Measure Steward
National Committee for Quality Assurance
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts
Quality ID
421
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Interventional Radiology
Primary Measure Steward
Society of Interventional Radiology
Appropriate Follow-up Imaging for Incidental Abdominal Lesions
Percentage of final reports for abdominal imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended
– Liver lesion =< 0.5 cm
- Cystic kidney lesion < 1.0 cm
- Adrenal lesion =< 1.0 cm
Quality ID
405
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
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
Quality ID
406
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomywho had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report
Quality ID
320
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Appropriate Testing for Children with Pharyngitis
Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode
Quality ID
66
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Emergency Medicine, Family Medicine, Pediatrics, Urgent Care
Primary Measure Steward
National Committee for Quality Assurance
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Percentage of children 3 months – 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode
Quality ID
65
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Otolaryngology, Pediatrics, Urgent Care
Primary Measure Steward
National Committee for Quality Assurance
Appropriate Treatment of Methicillin-Susceptible Staphylococcus Aureus (MSSA) Bacteremia
Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. Nafcillin, Oxacillin or Cefazolin) as definitive therapy
Quality ID
407
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Hospitalists, Infectious Disease
Primary Measure Steward
Infectious Diseases Society of America
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
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.
Quality ID
472
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Appropriate Workup Prior to Endometrial Ablation
Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation
Quality ID
448
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Obstetrics/Gynecology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period
Quality ID
326
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Skilled Nursing Facility
Primary Measure Steward
American College of Cardiology
Average Change in Back Pain Following Lumbar Discectomy/Laminotomy
The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure
Quality ID
459
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Neurosurgical
Primary Measure Steward
Minnesota Community Measurement
Average Change in Back Pain Following Lumbar Fusion
The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had a lumbar fusion procedure
Quality ID
460
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Neurosurgical
Primary Measure Steward
Minnesota Community Measurement
Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery
The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure
Quality ID
471
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Neurosurgical
Primary Measure Steward
Minnesota Community Measurement
Average Change in Functional Status Following Lumbar Fusion Surgery
The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients 18 years of age and older who had a lumbar fusion procedure
Quality ID
469
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Neurosurgical
Primary Measure Steward
Minnesota Community Measurement
Average Change In Functional Status Following Total Knee Replacement Surgery
The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement
Quality ID
470
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
Minnesota Community Measurement
Average Change in Leg Pain Following Lumbar Discectomy and/or Laminotomy
The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure
Quality ID
461
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Neurosurgical
Primary Measure Steward
Minnesota Community Measurement
Average Change in Leg Pain Following Lumbar Fusion Surgery
The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure
Quality ID
473
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Neurosurgical
Primary Measure Steward
Minnesota Community Measurement
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription
Quality ID
116
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Emergency Medicine, Family Medicine, Internal Medicine, Preventive Medicine, Urgent Care
Primary Measure Steward
National Committee for Quality Assurance
Barrett’s Esophagus
Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia
Quality ID
249
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Pathology
Primary Measure Steward
College of American Pathologists
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician
Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (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
Quality ID
440
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Dermatology
Primary Measure Steward
American Academy of Dermatology
Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient
Quality ID
265
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Dermatology, Obstetrics/Gynecology, Otolaryngology, Urology
Primary Measure Steward
American Academy of Dermatology
Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
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 (indicated by HCPCS code) 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
Quality ID
462
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Urology, Oncology
Primary Measure Steward
Oregon Urology Institute
Breast Cancer Screening
Percentage of women 50 – 74 years of age who had a mammogram to screen for breast cancer
Quality ID
112
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Family Medicine, Obstetrics/Gynecology, Preventive Medicine
Primary Measure Steward
National Committee for Quality Assurance
CAHPS for MIPs Clinician/Group Survey
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: – Getting timely care, appointments, and information;
– How well providers Communicate;
– Patient’s Rating of Provider;
– Access to Specialists;
– Health Promotion & Education;
– Shared Decision Making;
– Health Status/Functional Status;
– Courteous and Helpful Office Staff;
– Care Coordination; and
– Stewardship of Patient Resources
Quality ID
321
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Patient Engagement Experience
High Priority Measure?
TRUE
Data Submission Method
CSV
Specialty Measure Set
Family Medicine, Internal Medicine
Primary Measure Steward
Agency for Healthcare Research & Quality
Cardiac Rehabilitation Patient Referral from an Outpatient Setting
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
Quality ID
243
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine
Primary Measure Steward
American College of Cardiology Foundation
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period
Quality ID
322
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology
Primary Measure Steward
American College of Cardiology
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status
Quality ID
323
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology
Primary Measure Steward
American College of Cardiology
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment
Quality ID
324
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology
Primary Measure Steward
American College of Cardiology
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)
Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy
Quality ID
388
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cataract Surgery: Difference Between Planned and Final Refraction
Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction
Quality ID
389
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery
Quality ID
191
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence
Quality ID
192
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
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
Quality ID
303
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
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
Quality ID
304
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Patient Engagement Experience
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Academy of Ophthalmology
Cervical Cancer Screening
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
* Women age 21-64 who had cervical cytology performed every 3 years
* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Quality ID
309
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology
Primary Measure Steward
National Committee for Quality Assurance
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
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
Quality ID
382
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Pediatrics, Mental/Behavioral Health
Primary Measure Steward
Physician Consortium for Performance Improvement
Childhood Immunization Status
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday
Quality ID
240
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Children Who Have Dental Decay or Cavities
Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period
Quality ID
378
NQS Domain
Community/Population Health
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Dentistry
Primary Measure Steward
Centers for Medicare & Medicaid Services
Chlamydia Screening for Women
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
Quality ID
310
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Obstetrics/Gynecology, Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy
Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator
Quality ID
52
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Thoracic Society
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented
Quality ID
51
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Thoracic Society
Clinical Outcome Post Endovascular Stroke Treatment
Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention
Quality ID
409
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Interventional Radiology, Neurosurgical
Primary Measure Steward
Society of Interventional Radiology
Closing the Referral Loop: Receipt of Specialist Report
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
Quality ID
374
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Allergy/Immunology, Cardiology, Gastroenterology, Dermatology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventive Medicine, Neurology, Mental/Behavioral Health, Interventional Radiology, Vascular Surgery, General Surgery, Thoracic Surgery, Urology, Oncology, Rheumatology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Colonoscopy Interval for Patients with a History of Adenomatous Polyps
– Avoidance of Inappropriate Use
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy
Quality ID
185
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Colorectal Cancer Screening
Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer
Quality ID
113
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Family Medicine, Preventive Medicine
Primary Measure Steward
National Committee for Quality Assurance
Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication
Quality ID
24
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Preventive Medicine, Rheumatology
Primary Measure Steward
National Committee for Quality Assurance
Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment
Quality ID
468
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Physical Medicine, Mental/Behavioral Health
Primary Measure Steward
University of Southern California
Controlling High Blood Pressure
Percentage of patients 18 – 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period
Quality ID
236
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Vascular Surgery, Rheumatology
Primary Measure Steward
National Committee for Quality Assurance
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention
Quality ID
165
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis
Quality ID
167
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision
Quality ID
44
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Anesthesiology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours
Quality ID
164
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Stroke
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours
Quality ID
166
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason
Quality ID
168
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy
Quality ID
118
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Skilled Nursing Facility
Primary Measure Steward
American Heart Association
Coronary Artery Disease (CAD): Antiplatelet Therapy
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel
Quality ID
6
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Skilled Nursing Facility
Primary Measure Steward
American Heart Association
Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy
Quality ID
7
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Skilled Nursing Facility
Primary Measure Steward
Physician Consortium for Performance Improvement
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
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
Quality ID
283
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Neurology, Mental/Behavioral Health, Geriatrics
Primary Measure Steward
American Academy of Neurology
Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period
Quality ID
281
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Neurology, Mental/Behavioral Health, Geriatrics
Primary Measure Steward
Physician Consortium for Performance Improvement
Dementia: Education and Support of Caregivers for Patients with Dementia
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
Quality ID
288
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Neurology, Mental/Behavioral Health, Geriatrics
Primary Measure Steward
American Academy of Neurology
Dementia: Functional Status Assessment
Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months
Quality ID
282
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Neurology, Mental/Behavioral Health, Geriatrics
Primary Measure Steward
American Academy of Neurology
Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
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
Quality ID
286
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Neurology, Mental/Behavioral Health, Geriatrics
Primary Measure Steward
American Academy of Neurology
Depression Remission at Six Months
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 six months (+/- 60 days) after an index event date
Quality ID
411
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Mental/Behavioral Health
Primary Measure Steward
Minnesota Community Measurement
Depression Remission at Twelve Months
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
Quality ID
370
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
CMS Web Interface, EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Mental/Behavioral Health, Geriatrics
Primary Measure Steward
Minnesota Community Measurement
Depression Utilization of the PHQ-9 Tool
The percentage of adolescent patients 12 to 17 years of age and adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying depression encounter
Quality ID
371
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Mental/Behavioral Health
Primary Measure Steward
Minnesota Community Measurement
Developmental Screening in the First Three Years of Life
The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months preceding or on their first, second or third birthday
Quality ID
467
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Pediatrics
Primary Measure Steward
Oregon Health & Science University
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months
Quality ID
126
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Preventive Medicine, Podiatry
Primary Measure Steward
American Podiatric Medical Association
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing
Quality ID
127
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Podiatry
Primary Measure Steward
American Podiatric Medical Association
Diabetes: Eye Exam
Percentage of patients 18 – 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period
Quality ID
117
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Ophthalmology
Primary Measure Steward
National Committee for Quality Assurance
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Quality ID
1
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Preventive Medicine, Nephrology
Primary Measure Steward
National Committee for Quality Assurance
Diabetes: Medical Attention for Nephropathy
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Quality ID
119
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Preventive Medicine, Urology, Nephrology
Primary Measure Steward
National Committee for Quality Assurance
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months
Quality ID
19
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, EHR
Specialty Measure Set
Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration
Quality ID
130
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, EHR
Specialty Measure Set
Allergy/Immunology, Cardiology, Gastroenterology, Dermatology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Plastic Surgery, Preventive Medicine, Neurology, Mental/Behavioral Health, Vascular Surgery, General Surgery, Thoracic Surgery, Urology, Oncology, Hospitalists, Rheumatology, Nephrology, Infectious Disease, Neurosurgical, Physical Therapy/Occupational Therapy, Geriatrics, Urgent Care
Primary Measure Steward
Centers for Medicare & Medicaid Services
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record
Quality ID
412
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Physical Medicine, Neurology, Geriatrics
Primary Measure Steward
American Academy of Neurology
Door to Puncture Time for Endovascular Stroke Treatment
Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours
Quality ID
413
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Interventional Radiology, Neurosurgical
Primary Measure Steward
Society of Interventional Radiology
Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Quality ID
181
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Neurology, Mental/Behavioral Health, Geriatrics, Skilled Nursing Facility
Primary Measure Steward
Centers for Medicare & Medicaid Services
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT
Quality ID
415
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury
Quality ID
416
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
All female patients of childbearing potential (12 – 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year
Quality ID
268
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record
Quality ID
414
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Physical Medicine, Neurology, Geriatrics
Primary Measure Steward
American Academy of Neurology
Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
Quality ID
155
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventive Medicine, Neurology, Podiatry, Skilled Nursing Facility
Primary Measure Steward
National Committee for Quality Assurance
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
Quality ID
154
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventive Medicine, Neurology, Podiatry, Skilled Nursing Facility
Primary Measure Steward
National Committee for Quality Assurance
Falls: Screening for Future Fall Risk
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
Quality ID
318
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
CMS Web Interface, EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Nephrology, Podiatry
Primary Measure Steward
National Committee for Quality Assurance
Follow-Up After Hospitalization for Mental Illness (FUH)
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had 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 of discharge.- The percentage of discharges for which the patient received follow-up within 7 days of discharge.
Quality ID
391
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Pediatrics, Mental/Behavioral Health
Primary Measure Steward
National Committee for Quality Assurance
Follow-Up Care for Children Prescribed ADHD Medication (ADD)
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 Phaseb. 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
Quality ID
366
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Pediatrics, Mental/Behavioral Health
Primary Measure Steward
National Committee for Quality Assurance
Functional Outcome Assessment
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
Quality ID
182
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Physical Medicine, Nephrology, Physical Therapy/Occupational Therapy
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Assessment for Total Hip Replacement
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
Quality ID
376
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Assessment for Total Knee Replacement
Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery
Quality ID
375
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Assessments for Congestive Heart Failure
Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Quality ID
377
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.) The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
222
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with General Orthopedic Impairments
A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
223
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Hip Impairments
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 Hip FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
218
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Knee Impairments
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 Knee FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
217
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Low Back Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
220
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
219
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Shoulder Impairments
A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (Focus on Therapeutic Outcomes, Inc.).The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Quality ID
221
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Physical Therapy/Occupational Therapy
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
Quality ID
5
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Hospitalists
Primary Measure Steward
Physician Consortium for Performance Improvement
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
Quality ID
8
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Hospitalists, Skilled Nursing Facility
Primary Measure Steward
Physician Consortium for Performance Improvement
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
Percentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart
Quality ID
70
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
Physician Consortium for Performance Improvement
Hematology: Multiple Myeloma: Treatment with Bisphosphonates
Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period
Quality ID
69
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Society of Hematology
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow
Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow
Quality ID
67
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Society of Hematology
Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy
Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy
Quality ID
68
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Society of Hematology
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment
Quality ID
390
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission period
Quality ID
401
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology, Family Medicine, Internal Medicine
Primary Measure Steward
American Gastroenterological Association
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies
Percentage of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies
Quality ID
449
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
HIV Medical Visit Frequency
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
Quality ID
340
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Allergy/Immunology, Infectious Disease
Primary Measure Steward
Health Resources and Services Administration
HIV Screening
Percentage of patients 15-65 years of age who have been tested for human immunodeficiency virus (HIV).
Quality ID
475
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology, Preventive Medicine, Infectious Disease
Primary Measure Steward
Centers for Disease Control and Prevention
HIV Viral Load Suppression
The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year
Quality ID
338
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Allergy/Immunology, Family Medicine, Internal Medicine, Infectious Disease
Primary Measure Steward
Health Resources and Services Administration
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis
Quality ID
160
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Allergy/Immunology, Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection
Quality ID
205
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Pediatrics, Infectious Disease
Primary Measure Steward
National Committee for Quality Assurance
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is 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
Quality ID
392
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate
Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD
Quality ID
348
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
Infection rate following CIED device implantation, replacement, or revision
Quality ID
393
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
Image Confirmation of Successful Excision of Image-Localized Breast Lesion
Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy
Quality ID
262
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
American Society of Breast Surgeons
Immunizations for Adolescents
The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday
Quality ID
394
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
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
Quality ID
275
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment
Percentage of patients regardless of age with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the year prior and current year are considered adequately screened to prevent overuse of X-ray assessment
Quality ID
271
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.a. Percentage of patients who initiated treatment within 14 days of the diagnosisb. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit
Quality ID
305
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
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
Quality ID
441
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Vascular Surgery
Primary Measure Steward
Wisconsin Collaborative for Healthcare Quality
Lung Cancer Reporting (Biopsy/Cytology Specimens)
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 NSCLC-NOS with an explanation included in the pathology report
Quality ID
395
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Pathology
Primary Measure Steward
College of American Pathologists
Lung Cancer Reporting (Resection Specimens)
Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type
Quality ID
396
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Pathology
Primary Measure Steward
College of American Pathologists
Maternal Depression Screening
The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child’s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life
Quality ID
372
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
n/a
Primary Measure Steward
National Committee for Quality Assurance
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)
Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at >= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication
Quality ID
335
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
Centers for Medicare & Medicaid Services
Maternity Care: Post-Partum Follow-Up and Care Coordination
Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning
Quality ID
336
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
Centers for Medicare & Medicaid Services
Medication Management for People with Asthma
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period
Quality ID
444
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Medication Reconciliation Post-Discharge
The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical recordThis measure is reported as three rates stratified by age group:
– Submission Criteria 1: 18-64 years of age
– Submission Criteria 2: 65 years and older
– Total Rate: All patients 18 years of age and older
Quality ID
46
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Orthopedic Surgery, General Surgery, Nephrology, Geriatrics
Primary Measure Steward
National Committee for Quality Assurance
Melanoma Reporting
Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate
Quality ID
397
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Pathology
Primary Measure Steward
College of American Pathologists
Melanoma: Continuity of Care – Recall System
Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:
– A target date for the next complete physical skin exam, AND
– A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment
Quality ID
137
NQS Domain
Communication and Care Coordination
Measure Type
Structure
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Dermatology
Primary Measure Steward
American Academy of Dermatology
Melanoma: Coordination of Care
Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis
Quality ID
138
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Dermatology
Primary Measure Steward
American Academy of Dermatology
Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer
Quality ID
443
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology
Primary Measure Steward
National Committee for Quality Assurance
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed
Quality ID
147
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
Society of Nuclear Medicine and Molecular Imaging
Oncology: Medical and Radiation – Pain Intensity Quantified
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified
Quality ID
143
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Oncology, Radiation Oncology
Primary Measure Steward
Physician Consortium for Performance Improvement
Oncology: Medical and Radiation – Plan of Care for Moderate to Severe Pain
Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician
Quality ID
144
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology, Radiation Oncology
Primary Measure Steward
American Society of Clinical Oncology
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection
Quality ID
400
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Nephrology
Primary Measure Steward
Physician Consortium for Performance Improvement
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories
Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool
Quality ID
446
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
n/a
Primary Measure Steward
Society of Thoracic Surgeons
Opioid Therapy Follow-up Evaluation
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
Quality ID
408
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Physical Medicine, Neurology, Geriatrics
Primary Measure Steward
American Academy of Neurology
Optimal Asthma Control
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
Quality ID
398
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Otolaryngology, Pediatrics
Primary Measure Steward
Minnesota Community Measurement
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
Percentage of final reports for 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)
Quality ID
364
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study
Quality ID
362
NQS Domain
Communication and Care Coordination
Measure Type
Structure
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study
Quality ID
360
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements
Quality ID
361
NQS Domain
Patient Safety
Measure Type
Structure
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
Quality ID
109
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Orthopedic Surgery, Physical Medicine, Preventive Medicine
Primary Measure Steward
American Academy of Orthopedic Surgeons
Osteoporosis Management in Women Who Had a Fracture
The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture
Quality ID
418
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology, Orthopedic Surgery
Primary Measure Steward
National Committee for Quality Assurance
Otitis Media with Effusion: Systemic Antimicrobials – Avoidance of Inappropriate Use
Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials
Quality ID
464
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Otolaryngology, Pediatrics, Infectious Disease, Urgent Care
Primary Measure Steward
American Academy of Otolaryngology – Head and Neck Surgery Foundation
Overuse of Imaging for the Evaluation of Primary Headache
Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present
Quality ID
419
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Pain Assessment and Follow-Up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
Quality ID
131
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Orthopedic Surgery, Physical Medicine, Urology, Rheumatology, Physical Therapy/Occupational Therapy, Geriatrics, Urgent Care
Primary Measure Steward
Centers for Medicare & Medicaid Services
Pain Brought Under Control Within 48 Hours
Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours
Quality ID
342
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine
Primary Measure Steward
National Hospice and Palliative Care Organization
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease
Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 months
Quality ID
291
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease
Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms in the past 12 months
Quality ID
290
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Parkinson’s Disease: Rehabilitative Therapy Options
Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 months
Quality ID
293
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon
Quality ID
358
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Otolaryngology, Plastic Surgery, Vascular Surgery, General Surgery, Thoracic Surgery, Urology
Primary Measure Steward
American College of Surgeons
Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
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
Quality ID
452
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL
Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL
Quality ID
328
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Nephrology
Primary Measure Steward
Renal Physicians Association
Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence
Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines
Quality ID
428
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Obstetrics/Gynecology, Urology
Primary Measure Steward
American Urogynecologic Society
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy
Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse
Quality ID
429
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Obstetrics/Gynecology, Urology
Primary Measure Steward
American Urogynecologic Society
Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)
Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there
Quality ID
457
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)
Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life
Quality ID
455
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology, Geriatrics
Primary Measure Steward
American Society of Clinical Oncology
Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score – better)
Percentage of patients who died from cancer not admitted to hospice
Quality ID
456
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)
Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life
Quality ID
453
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score – better)
Percentage of patients who died from cancer with more than one emergency department visit in the last 30 days of life
Quality ID
454
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
Quality ID
422
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Obstetrics/Gynecology
Primary Measure Steward
American Urogynecologic Society
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin
Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis
Quality ID
21
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Orthopedic Surgery, Otolaryngology, Plastic Surgery, Vascular Surgery, General Surgery, Thoracic Surgery, Neurosurgical
Primary Measure Steward
American Society of Plastic Surgeons
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time
Quality ID
23
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Orthopedic Surgery, Otolaryngology, Plastic Surgery, Vascular Surgery, General Surgery, Thoracic Surgery, Urology, Neurosurgical
Primary Measure Steward
American Society of Plastic Surgeons
Perioperative Temperature Management
Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Quality ID
424
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Persistence of Beta-Blocker Treatment After a Heart Attack
The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with adiagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge
Quality ID
442
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine
Primary Measure Steward
National Committee for Quality Assurance
Photodocumentation of Cecal Intubation
The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination
Quality ID
425
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Society for Gastrointestinal Endoscopy
Pneumococcal Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
Quality ID
111
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, EHR
Specialty Measure Set
Allergy/Immunology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Otolaryngology, Preventive Medicine, Oncology, Rheumatology, Nephrology, Infectious Disease, Geriatrics
Primary Measure Steward
National Committee for Quality Assurance
Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
Quality ID
76
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Anesthesiology, Interventional Radiology, Hospitalists
Primary Measure Steward
American Society of Anesthesiologists
Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively
Quality ID
430
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
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
Quality ID
463
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounterNormal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
Quality ID
128
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, EHR
Specialty Measure Set
Cardiology, Gastroenterology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventive Medicine, Mental/Behavioral Health, Vascular Surgery, General Surgery, Urology, Rheumatology, Podiatry, Physical Therapy/Occupational Therapy
Primary Measure Steward
Centers for Medicare & Medicaid Services
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
Quality ID
110
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Allergy/Immunology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Otolaryngology, Pediatrics, Preventive Medicine, Oncology, Rheumatology, Nephrology, Infectious Disease, Geriatrics, Skilled Nursing Facility
Primary Measure Steward
Physician Consortium for Performance Improvement
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Quality ID
134
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Family Medicine, Internal Medicine, Orthopedic Surgery, Pediatrics, Preventive Medicine, Neurology, Mental/Behavioral Health
Primary Measure Steward
Centers for Medicare & Medicaid Services
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated
Quality ID
317
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, EHR
Specialty Measure Set
Allergy/Immunology, Cardiology, Gastroenterology, Dermatology, Emergency Medicine, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Plastic Surgery, Preventive Medicine, Neurology, Mental/Behavioral Health, Vascular Surgery, General Surgery, Thoracic Surgery, Urology, Oncology, Rheumatology, Nephrology, Urgent Care, Skilled Nursing Facility
Primary Measure Steward
Centers for Medicare & Medicaid Services
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Quality ID
226
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, CMS Web Interface, EHR
Specialty Measure Set
Allergy/Immunology, Cardiology, Gastroenterology, Dermatology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Plastic Surgery, Preventive Medicine, Neurology, Mental/Behavioral Health, Vascular Surgery, General Surgery, Thoracic Surgery, Urology, Oncology, Rheumatology, Neurosurgical, Podiatry, Urgent Care
Primary Measure Steward
Physician Consortium for Performance Improvement
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
Quality ID
431
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Gastroenterology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Otolaryngology, Physical Medicine, Preventive Medicine, Neurology, Mental/Behavioral Health, Urology, Oncology, Urgent Care
Primary Measure Steward
Physician Consortium for Performance Improvement
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period
Quality ID
379
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Pediatrics, Dentistry
Primary Measure Steward
Centers for Medicare & Medicaid Services
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months
Quality ID
12
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, EHR
Specialty Measure Set
Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period
Quality ID
141
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 30 days after surgery
Quality ID
432
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Obstetrics/Gynecology, Urology
Primary Measure Steward
American Urogynecologic Society
Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery
Quality ID
433
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Obstetrics/Gynecology, Urology
Primary Measure Steward
American Urogynecologic Society
Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery
Quality ID
434
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Obstetrics/Gynecology, Urology
Primary Measure Steward
American Urogynecologic Society
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
Quality ID
102
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Urology, Oncology, Radiation Oncology
Primary Measure Steward
Physician Consortium for Performance Improvement
Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate
Quality ID
104
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Urology
Primary Measure Steward
American Urological Association Education and Research
Psoriasis: Clinical Response to Systemic Medications
Percentage of psoriasis vulgaris patients receiving systemic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment
Quality ID
410
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Dermatology
Primary Measure Steward
American Academy of Dermatology
Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier
Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test
Quality ID
337
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Dermatology, Family Medicine, Internal Medicine
Primary Measure Steward
American Academy of Dermatology
Quality of Life Assessment For Patients With Primary Headache Disorders
Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved
Quality ID
435
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Neurology
Primary Measure Steward
American Academy of Neurology
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used
– Automated exposure control
– Adjustment of the mA and/or kV according to patient size
– Use of iterative reconstruction technique
Quality ID
436
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology/Ameri can Medical AssociationPhysician Consortium for Performance Improvement/ National Committee for Quality Assurance
Radical Prostatectomy Pathology Reporting
Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status
Quality ID
250
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Pathology, Oncology
Primary Measure Steward
College of American Pathologists
Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)
Quality ID
145
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology, Interventional Radiology
Primary Measure Steward
American College of Radiology
Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms
Percentage of final reports for screening mammograms that are classified as “probably benign”
Quality ID
146
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Radiology: Reminder System for Screening Mammograms
Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram
Quality ID
225
NQS Domain
Communication and Care Coordination
Measure Type
Structure
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Radiology: Stenosis Measurement in Carotid Imaging Reports
Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement
Quality ID
195
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Diagnostic Radiology
Primary Measure Steward
American College of Radiology
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
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
Quality ID
451
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive
Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery
Quality ID
345
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Vascular Surgery, Neurosurgical
Primary Measure Steward
Society for Vascular Surgeons
Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive
Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery
Quality ID
346
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Vascular Surgery, Neurosurgical
Primary Measure Steward
Society for Vascular Surgeons
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2
Quality ID
344
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Cardiology, Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2
Quality ID
260
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive
Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive
Quality ID
347
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
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)
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)
Quality ID
259
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive
Percentage of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive
Quality ID
417
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Vascular Surgery
Primary Measure Steward
Society for Vascular Surgery
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)
Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)
Quality ID
258
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure
Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure
Quality ID
437
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Interventional Radiology
Primary Measure Steward
Society of Interventional Radiology
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
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
Quality ID
261
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
n/a
Primary Measure Steward
Audiology Quality Consortium
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh Immunoglobulin (Rhogam) in the emergency department (ED)
Quality ID
255
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months
Quality ID
179
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months
Quality ID
178
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >= 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months
Quality ID
180
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery, Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity at >= 50% of encounters for RA for each patient during the measurement year
Quality ID
177
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Tuberculosis Screening
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who havedocumentation of a tuberculosis (TB) screening performed and results interpreted within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
Quality ID
176
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Rheumatology
Primary Measure Steward
American College of Rheumatology
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
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
Quality ID
445
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Screening Colonoscopy Adenoma Detection Rate
The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy
Quality ID
343
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Gastroenterology
Primary Measure Steward
American Society for Gastrointestinal Endoscopy
Screening for Osteoporosis for Women Aged 65-85 Years of Age
Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis
Quality ID
39
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Preventive Medicine, Rheumatology, Geriatrics
Primary Measure Steward
National Committee for Quality Assurance
Sentinel Lymph Node Biopsy for Invasive Breast Cancer
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
Quality ID
264
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
General Surgery
Primary Measure Steward
American Society of Breast Surgeons
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
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
Quality ID
279
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Internal Medicine, Otolaryngology
Primary Measure Steward
American Academy of Sleep Medicine
Sleep Apnea: Severity Assessment at Initial Diagnosis
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
Quality ID
277
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Internal Medicine, Otolaryngology
Primary Measure Steward
American Academy of Sleep Medicine
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Percentage of the following patients – all considered at high risk of cardiovascular events – who were prescribed or were on statin therapy during the measurement period:
* Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
* Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
* Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
Quality ID
438
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
CMS Web Interface, EHR
Specialty Measure Set
Cardiology, Family Medicine, Internal Medicine, Preventive Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well
Quality ID
187
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Emergency Medicine, Neurosurgical
Primary Measure Steward
American Heart Association
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
Quality ID
357
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Otolaryngology, Plastic Surgery, Vascular Surgery, General Surgery
Primary Measure Steward
American College of Surgeons
Tobacco Use and Help with Quitting Among Adolescents
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
Quality ID
402
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Allergy/Immunology, Cardiology, Gastroenterology, Dermatology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Orthopedic Surgery, Otolaryngology, Pediatrics, Physical Medicine, Preventive Medicine, Neurology, Mental/Behavioral Health, Vascular Surgery, General Surgery, Thoracic Surgery, Oncology, Rheumatology, Urgent Care
Primary Measure Steward
National Committee for Quality Assurance
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant
Quality ID
353
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
Quality ID
352
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
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. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure
Quality ID
350
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
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)
Quality ID
351
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy
Percentage of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving Trastuzumab
Quality ID
450
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Oncology
Primary Measure Steward
American Society of Clinical Oncology
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location
Quality ID
254
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
Quality ID
356
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Plastic Surgery, General Surgery
Primary Measure Steward
American College of Surgeons
Unplanned Reoperation within the 30 Day Postoperative Period
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period
Quality ID
355
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Plastic Surgery, General Surgery
Primary Measure Steward
American College of Surgeons
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
Quality ID
48
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology, Preventive Medicine, Urology
Primary Measure Steward
National Committee for Quality Assurance
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months
Quality ID
50
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Claims, Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Obstetrics/Gynecology, Urology, Geriatrics
Primary Measure Steward
National Committee for Quality Assurance
Use of High-Risk Medications in the Elderly
Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.
1) Percentage of patients who were ordered at least one high-risk medication
2) Percentage of patients who were ordered at least two of the same high-risk medication
Quality ID
238
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
EHR
Specialty Measure Set
Allergy/Immunology, Cardiology, Family Medicine, Internal Medicine, Rheumatology, Geriatrics
Primary Measure Steward
National Committee for Quality Assurance
Uterine Artery Embolization Technique: Documenttion of Angigraphic Endpoints and Interrogation of Ovarian Arteries
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
Quality ID
465
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Interventional Radiology
Primary Measure Steward
Society of Interventional Radiology
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment
Quality ID
420
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure?
TRUE
Data Submission Method
Registry
Specialty Measure Set
Interventional Radiology, Vascular Surgery
Primary Measure Steward
Society of Interventional Radiology
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.
– Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
– Percentage of patients with counseling for nutrition
– Percentage of patients with counseling for physical activity
Quality ID
239
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
EHR
Specialty Measure Set
Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Zoster (Shingles) Vaccination
The percentage of patients aged 50 years and older who have had a Varicella Zoster (shingles) vaccination.
Quality ID
474
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure?
FALSE
Data Submission Method
Registry
Specialty Measure Set
Family Medicine, Internal Medicine, Preventive Medicine, Oncology, Nephrology, Infectious Disease, Geriatrics, Skilled Nursing Facility
Primary Measure Steward
PPRNet
