Quality

MIPS Performance Category

The Quality performance category replaced the Physician Quality Reporting System (PQRS). It covers the quality of the care providers deliver, based on performance measures created by the CMS, as well as medical professional and stakeholder groups. Providers pick the six measures of performance that best fit their practices.

Scroll down to view a summary of the Quality performance category, as well as the full list of 257 Quality Measures for 2019.

Or click a tab below to learn more about MIPS or any of the other three Performance Categories.


Quality: 2019 Key Facts


45%


For 2019, the Quality category makes up 45% of a provider’s final MIPS score, down 5% from 2018.

Meeting the Requirements


The Quality performance category was created to measure clinicians’ quality of care. Providers must submit a full year’s worth of data for 6 Quality Measures (from the CMS’ list) to earn full credit. It’s important for providers to carefully follow the specific data collection and submission requirements for the Quality Measures they choose, as they can vary.

Scoring


Providers are scored by weighing their performance against specific benchmarks for individual Quality measures. Providers can earn bonus points for submitting more than one Outcome/High-Priority measure (in forms other than the CMS Web Interface). Small practices can also earn up to 6 bonus points for simply submitting data for one quality measure. Finally, all providers can earn up to 10 bonus points based on their year-over-year improvement in score.

Browse the Full List of 2019 Quality Measures

For the 2019 MIPS Performance Year, there are 257 Quality Measures, many of which are categorized into various Specialty Measure Sets. Providers must submit data for either 6 different Quality Measures or one complete Specialty Measure Set (or at least 6 measures from a Specialty Set, if the set contains more than 6 measures). Providers must also submit data for at least one Outcome Measure, or an alternative high-priority measure if no Outcome measure is available. For the most part, the reporting requirements are greater for larger physician groups.

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

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