Quality Payment Program Quality Measures

Quality is one of the four performance categories of the Quality Payment Program. It will replace the existing Physician Quality Reporting System (PQRS). The quality measure details service returns the list of all measures in this category. The results include the different identifier numbers used to refer to this measure in different indices: CMS, NQF, and Quality.

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: 0654
Quality ID: 093

NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method

  • Claims
  • Registry

Specialty Measure Set

  • Emergency Medicine
  • Otolaryngology
  • General Practice/Family Medicine
  • Pediatrics

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: 0653
Quality ID: 091

NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

Yes

Data Submission Method

  • Claims
  • Registry

Specialty Measure Set

  • Emergency Medicine
  • Otolaryngology
  • Pediatrics

Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication

Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

Measure Number

eMeasure ID: CMS136v6
eMeasure NQF: N/A
NQF: 0108
Quality ID: 366

NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method

  • EHR

Specialty Measure Set

  • Mental/Behavioral Health
  • Pediatrics

Primary Measure Steward

National Committee for Quality Assurance

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)

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: 1879
Quality ID: 383

NQS Domain

Patient Safety

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Mental/Behavioral Health

Primary Measure Steward

Health Services Advisory Group

Adult Kidney Disease: Blood Pressure Management

Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 122

NQS Domain

Effective Clinical Care

Measure Type

Intermediate Outcome

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

Primary Measure Steward

Renal Physicians Association

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 329

NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 330

NQS Domain

Patient Safety

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 403

NQS Domain

Person and Caregiver-Centered Experience and Outcomes

Measure Type

Process

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 325

NQS Domain

Communication and Care Coordination

Measure Type

Process

High Priority Measure

Yes

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

Measure Number

eMeasure ID: CMS161v5
eMeasure NQF: N/A
NQF: 0104
Quality ID: 107

NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method

  • EHR

Specialty Measure Set

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 384

NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 385

NQS Domain

Effective Clinical Care

Measure Type

Outcome

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Ophthalmology

Primary Measure Steward

American Academy of Ophthalmology

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)

Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 331

NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 332

NQS Domain

Efficiency and Cost Reduction

Measure Type

Process

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 333

NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine

Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)

Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 334

NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Allergy/Immunology
  • Internal Medicine
  • Otolaryngology
  • General Practice/Family Medicine

Primary Measure Steward

American Academy of Otolaryngology-Head and Neck Surgery

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

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: N/A
Quality ID: 439

NQS Domain

Efficiency and Cost Reduction

Measure Type

Efficiency

High Priority Measure

Yes

Data Submission Method

  • Registry

Specialty Measure Set

  • Gastroenterology

Primary Measure Steward

American Gastroenterological Association

Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: 0566
Quality ID: 140

NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

Data Submission Method

  • Claims
  • Registry

Specialty Measure Set

  • Ophthalmology

Primary Measure Steward

American Academy of Ophthalmology

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 hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: 0087
Quality ID: 014

NQS Domain

Effective Clinical Care

Measure Type

Process

High Priority Measure

No

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.

Measure Number

eMeasure ID: N/A
eMeasure NQF: N/A
NQF: 1789
Quality ID: 458

NQS Domain

Communication and Care Coordination

Measure Type

Outcome

High Priority Measure

No

Data Submission Method

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 386

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 354

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Surgery

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 404

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 387

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • General Practice/Family 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).

    Measure Number

    eMeasure ID: CMS128v5
    eMeasure NQF: N/A
    NQF: 0105
    Quality ID: 009

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Internal Medicine
    • Mental/Behavioral Health
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 421

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Society of Interventional Radiology

    Appropriate Follow-up Imaging for Incidental Abdominal Lesions

    Percentage of final reports for abdominal imaging studies for asymptomatic 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 405

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    Yes

    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 or ultrasound of the 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 406

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    Yes

    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 polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0658
    Quality ID: 320

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: CMS146v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 066

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • Emergency Medicine
    • General Practice/Family Medicine
    • Pediatrics

    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

    Measure Number

    eMeasure ID: CMS154v5
    eMeasure NQF: N/A
    NQF: 0069
    Quality ID: 065

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • General Practice/Family Medicine
    • Pediatrics

    Primary Measure Steward

    National Committee for Quality Assurance

    Appropriate Treatment of Methicillin-Sensitive 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 407

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Hospitalists

    Primary Measure Steward

    Infectious Diseases Society of America

    Appropriate Workup Prior to Endometrial Ablation

    Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy before undergoing an endometrial ablation

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0567
    Quality ID: 448

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    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 a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1525
    Quality ID: 326

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • General Practice/Family Medicine

    Primary Measure Steward

    American College of Cardiology

    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 dispensed an antibiotic prescription

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0058
    Quality ID: 116

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Emergency Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1854
    Quality ID: 249

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Pathology

    Primary Measure Steward

    College of American Pathologists

    Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: 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 of biopsy date

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 440

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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 by the performing physician

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 265

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Dermatology
    • Interventional Radiology
    • Obstetrics/Gynecology
    • Urology

    Primary Measure Steward

    American Academy of Dermatology

    Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

    Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

    Measure Number

    eMeasure ID: CMS169v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 367

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    Primary Measure Steward

    Center for Quality Assessment and Improvement in Mental Health

    Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

    Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0391
    Quality ID: 099

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Pathology

    Primary Measure Steward

    College of American Pathologists

    Breast Cancer Screening

    Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

    Measure Number

    eMeasure ID: CMS125v5
    eMeasure NQF: N/A
    NQF: 2372
    Quality ID: 112

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    CAHPS for MIPS Clinician/Group Survey

    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; Between Visit Communication; Helping Your to Take Medication as Directed; and Stewardship of Patient Resources

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0006 & 0005
    Quality ID: 321

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Patient Engagement/Experience

    High Priority Measure

    Yes

    Data Submission Method

    • CSV

    Specialty Measure Set

    • General Practice/Family 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0643
    Quality ID: 243

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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 reporting period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 322

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Efficiency

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 323

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Efficiency

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 324

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Efficiency

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Cardiology

    Primary Measure Steward

    American College of Cardiology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0326
    Quality ID: 047

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    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

    Measure Number

    eMeasure ID: CMS133v5
    eMeasure NQF: N/A
    NQF: 0565
    Quality ID: 191

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    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

    Measure Number

    eMeasure ID: CMS132v5
    eMeasure NQF: N/A
    NQF: 0564
    Quality ID: 192

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1536
    Quality ID: 303

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 304

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 389

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Ophthalmology

    Primary Measure Steward

    American Academy of Ophthalmology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 388

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Ophthalmology

    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

    Measure Number

    eMeasure ID: CMS124v5
    eMeasure NQF: N/A
    NQF: 0032
    Quality ID: 309

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Obstetrics/Gynecology
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: CMS177v5
    eMeasure NQF: N/A
    NQF: 1365
    Quality ID: 382

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Mental/Behavioral Health
    • Pediatrics

    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

    Measure Number

    eMeasure ID: CMS117v5
    eMeasure NQF: N/A
    NQF: 0038
    Quality ID: 240

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: CMS75v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 378

    NQS Domain

    Community/Population Health

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • EHR

    Specialty Measure Set

    Primary Measure Steward

    Centers for Medicare & Medicaid Services

    Chlamydia Screening and Follow Up

    The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 447

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Obstetrics/Gynecology

    Primary Measure Steward

    National Committee for Quality Assurance

    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

    Measure Number

    eMeasure ID: CMS153v5
    eMeasure NQF: N/A
    NQF: 0033
    Quality ID: 310

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    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 an long-acting inhaled bronchodilator

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0102
    Quality ID: 052

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0091
    Quality ID: 051

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 409

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: CMS50v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 374

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0659
    Quality ID: 185

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Gastroenterology

    Primary Measure Steward

    American Gastroenterological Association

    Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

    Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0392
    Quality ID: 100

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Pathology

    Primary Measure Steward

    College of American Pathologists

    Colorectal Cancer Screening

    Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.

    Measure Number

    eMeasure ID: CMS130v5
    eMeasure NQF: N/A
    NQF: 0034
    Quality ID: 113

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • General Practice/Family 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 reported by the physician who treats the fracture and who therefore is held accountable for the communication

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0045
    Quality ID: 024

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Preventive Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    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 (<140/90mmHg) during the measurement period

    Measure Number

    eMeasure ID: CMS165v5
    eMeasure NQF: N/A
    NQF: 0018
    Quality ID: 236

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • Obstetrics/Gynecology
    • Preventive Medicine
    • Thoracic Surgery
    • Vascular Surgery
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0130
    Quality ID: 165

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0114
    Quality ID: 167

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0236
    Quality ID: 044

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0129
    Quality ID: 164

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0131
    Quality ID: 166

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0115
    Quality ID: 168

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Thoracic Surgery

    Primary Measure Steward

    Society of Thoracic Surgeons

    Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

    Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0134
    Quality ID: 043

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0066
    Quality ID: 118

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Cardiology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0067
    Quality ID: 006

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Cardiology

    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

    Measure Number

    eMeasure ID: CMS145v5
    eMeasure NQF: N/A
    NQF: 0070
    Quality ID: 007

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • Cardiology
    • General Practice/Family Medicine

    Primary Measure Steward

    Physician Consortium for Performance Improvement

    Dementia: Caregiver Education and Support

    Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 288

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology
    • Mental/Behavioral Health

    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

    Measure Number

    eMeasure ID: CMS149v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 281

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Neurology
    • Mental/Behavioral Health

    Primary Measure Steward

    Physician Consortium for Performance Improvement

    Dementia: Counseling Regarding Safety Concerns

    Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 286

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology
    • Mental/Behavioral Health

    Primary Measure Steward

    American Academy of Neurology

    Dementia: Functional Status Assessment

    Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 282

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology
    • Mental/Behavioral Health

    Primary Measure Steward

    American Academy of Neurology

    Dementia: Management of Neuropsychiatric Symptoms

    Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 284

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology
    • Mental/Behavioral Health

    Primary Measure Steward

    American Academy of Neurology

    Dementia: Neuropsychiatric Symptom Assessment

    Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 283

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology
    • Mental/Behavioral Health

    Primary Measure Steward

    American Academy of Neurology

    Depression Remission at Six Months

    Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0711
    Quality ID: 411

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Mental/Behavioral Health

    Primary Measure Steward

    Minnesota Community Measurement

    Depression Remission at Twelve Months

    Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

    Measure Number

    eMeasure ID: CMS159v5
    eMeasure NQF: N/A
    NQF: 0710
    Quality ID: 370

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Mental/Behavioral Health
    • General Practice/Family Medicine

    Primary Measure Steward

    Minnesota Community Measurement

    Depression Utilization of the PHQ-9 Tool

    Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit

    Measure Number

    eMeasure ID: CMS160v5
    eMeasure NQF: N/A
    NQF: 0712
    Quality ID: 371

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Mental/Behavioral Health

    Primary Measure Steward

    Minnesota Community Measurement

    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 exam (no evidence of retinopathy) in the 12 months prior to the measurement period

    Measure Number

    eMeasure ID: CMS131v5
    eMeasure NQF: N/A
    NQF: 0055
    Quality ID: 117

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Ophthalmology
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    Diabetes: Foot Exam

    The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year

    Measure Number

    eMeasure ID: CMS123v5
    eMeasure NQF: N/A
    NQF: 0056
    Quality ID: 163

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Internal Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: CMS122v5
    eMeasure NQF: N/A
    NQF: 0059
    Quality ID: 001

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Preventive Medicine
    • General Practice/Family Medicine

    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.

    Measure Number

    eMeasure ID: CMS134v5
    eMeasure NQF: N/A
    NQF: 0062
    Quality ID: 119

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0417
    Quality ID: 126

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0416
    Quality ID: 127

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    American Podiatric Medical Association

    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

    Measure Number

    eMeasure ID: CMS142v5
    eMeasure NQF: N/A
    NQF: 0089
    Quality ID: 019

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • EHR
    • Registry

    Specialty Measure Set

    • Ophthalmology

    Primary Measure Steward

    Physician Consortium for Performance Improvement

    Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

    Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months

    Measure Number

    eMeasure ID: CMS167v5
    eMeasure NQF: N/A
    NQF: 0088
    Quality ID: 018

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • 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 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.

    Measure Number

    eMeasure ID: CMS68v6
    eMeasure NQF: N/A
    NQF: 0419
    Quality ID: 130

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • EHR
    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • Internal Medicine
    • Anesthesiology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery
    • General Practice/Family Medicine

    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.

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 412

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Neurology
    • Physical Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 413

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 181

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Mental/Behavioral Health
    • General Practice/Family Medicine

    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 within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 415

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Efficiency

    High Priority Measure

    Yes

    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 within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 416

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Efficiency

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1814
    Quality ID: 268

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 414

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Neurology
    • Physical Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0101
    Quality ID: 155

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0101
    Quality ID: 154

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • General Practice/Family Medicine

    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.

    Measure Number

    eMeasure ID: CMS139v5
    eMeasure NQF: N/A
    NQF: 0101
    Quality ID: 318

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • CMS Web Interface
    • EHR

    Specialty Measure Set

    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 an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0576
    Quality ID: 391

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Mental/Behavioral Health
    • Pediatrics

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2624
    Quality ID: 182

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Physical Medicine

    Primary Measure Steward

    Centers for Medicare & Medicaid Services

    Functional Status Assessment for Total Hip Replacement

    Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments

    Measure Number

    eMeasure ID: CMS56v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 376

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    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 with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments

    Measure Number

    eMeasure ID: CMS66v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 375

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    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 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments

    Measure Number

    eMeasure ID: CMS90v6
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 377

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR

    Specialty Measure Set

    Primary Measure Steward

    Centers for Medicare & Medicaid Services

    Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

    A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0427
    Quality ID: 222

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Focus on Therapeutic Outcomes, Inc.

    Functional Status Change for Patients with Foot or Ankle Impairments

    A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0424
    Quality ID: 219

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Focus on Therapeutic Outcomes, Inc.

    Functional Status Change for Patients with General Orthopaedic Impairments

    A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0428
    Quality ID: 223

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Focus on Therapeutic Outcomes, Inc.

    Functional Status Change for Patients with Hip Impairments

    A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0423
    Quality ID: 218

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Focus on Therapeutic Outcomes, Inc.

    Functional Status Change for Patients with Knee Impairments

    A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0422
    Quality ID: 217

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Focus on Therapeutic Outcomes, Inc.

    Functional Status Change for Patients with Lumbar Impairments

    A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0425
    Quality ID: 220

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Focus on Therapeutic Outcomes, Inc.

    Functional Status Change for Patients with Shoulder Impairments

    A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0426
    Quality ID: 221

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: CMS135v5
    eMeasure NQF: 2907
    NQF: 0081
    Quality ID: 005

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • Hospitalists
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: CMS144v5
    eMeasure NQF: 2908
    NQF: 0083
    Quality ID: 008

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • Cardiology
    • Hospitalists
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0379
    Quality ID: 070

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0380
    Quality ID: 069

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0377
    Quality ID: 067

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0378
    Quality ID: 068

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 390

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    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 reporting period

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 401

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Gastroenterology
    • General Practice/Family Medicine

    Primary Measure Steward

    American Gastroenterological Association

    HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies

    Proportion 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1857
    Quality ID: 449

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    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

    Measure Number

    eMeasure ID: CMS52v5
    eMeasure NQF: N/A
    NQF: 0405
    Quality ID: 160

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0409
    Quality ID: 205

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Pediatrics

    Primary Measure Steward

    National Committee for Quality Assurance

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2079
    Quality ID: 340

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Health Resources and Services Administration

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2082
    Quality ID: 338

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Practice/Family Medicine

    Primary Measure Steward

    Health Resources and Services Administration

    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 reported as four rates stratified by age and gender: Reporting Age Criteria 1: Females 18-64years of age Reporting Age Criteria 2: Males 18-64 years of age Reporting Age Criteria 3: Females 65 years of age and older Reporting Age Criteria 4: Males 65 years of age and older

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2474
    Quality ID: 392

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 348

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 393

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Electrophysiology Cardiac Specialist

    Primary Measure Steward

    The Heart Rhythm Society

    Hypertension: Improvement in Blood Pressure

    Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

    Measure Number

    eMeasure ID: CMS65v6
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 373

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • EHR

    Specialty Measure Set

    Primary Measure Steward

    Centers for Medicare & Medicaid Services

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 262

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1407
    Quality ID: 394

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Practice/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 aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 275

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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 aged 18 years and older 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 271

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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 diagnosis. b. 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.

    Measure Number

    eMeasure ID: CMS137v5
    eMeasure NQF: N/A
    NQF: 0004
    Quality ID: 305

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    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 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 441

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Wisconsin Collaborative for Healthcare Quality

    Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

    Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.

    Measure Number

    eMeasure ID: CMS164v5
    eMeasure NQF: N/A
    NQF: 0068
    Quality ID: 204

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    KRAS 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 KRAS gene mutation testing was performed

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1859
    Quality ID: 451

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 395

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 396

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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.

    Measure Number

    eMeasure ID: CMS82v4
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 372

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 335

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 336

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1799
    Quality ID: 444

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • General Practice/Family 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 record. This measure is reported as three rates stratified by age group: Reporting Criteria 1: 18-64 years of age Reporting Criteria 2: 65 years and older Total Rate: All patients 18 years of age and older

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0097
    Quality ID: 046

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • CMS Web Interface
    • Registry

    Specialty Measure Set

    Primary Measure Steward

    National Committee for Quality Assurance

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0650
    Quality ID: 137

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Structure

    High Priority Measure

    Yes

    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 who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 138

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Dermatology

    Primary Measure Steward

    American Academy of Dermatology

    Melanoma: Overutilization of Imaging Studies in Melanoma

    Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0562
    Quality ID: 224

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Dermatology

    Primary Measure Steward

    American Academy of Dermatology

    Melanoma Reporting

    Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 397

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Pathology

    Primary Measure Steward

    College of American Pathologists

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 443

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Obstetrics/Gynecology
    • General Practice/Family Medicine

    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, MRI, CT, etc.) that were performed

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 147

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: CMS157v5
    eMeasure NQF: N/A
    NQF: 0384
    Quality ID: 143

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • General Oncology
    • Radiation Oncology

    Primary Measure Steward

    Physician Consortium for Performance Improvement

    Oncology: Medical and Radiation - Plan of Care for Pain

    Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0383
    Quality ID: 144

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Radiation Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Oncology: Radiation Dose Limits to Normal Tissues

    Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0382
    Quality ID: 156

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Radiation Oncology

    Primary Measure Steward

    American Society for Radiation 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 400

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0733
    Quality ID: 446

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 408

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Neurology
    • Physical Medicine
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 398

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • General Practice/Family Medicine

    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 computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 364

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 362

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Structure

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 360

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    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 reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 361

    NQS Domain

    Patient Safety

    Measure Type

    Structure

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Diagnostic Radiology

    Primary Measure Steward

    American College of Radiology

    Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive

    Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 363

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Structure

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Diagnostic Radiology

    Primary Measure Steward

    American College of Radiology

    Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description

    Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution's computer systems

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 359

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 109

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Orthopedic Surgery
    • Physical Medicine
    • Preventive Medicine
    • General Practice/Family 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 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0053
    Quality ID: 418

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Obstetrics/Gynecology
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination

    Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 419

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Efficiency

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0420
    Quality ID: 131

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Physical Medicine

    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) that report pain was brought to a comfortable level within 48 hours

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 342

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Practice/Family Medicine

    Primary Measure Steward

    National Hospice and Palliative Care Organization

    Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment

    All patients with a diagnosis of Parkinson's disease who were assessed for cognitive impairment or dysfunction in the last 12 months

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 291

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology

    Primary Measure Steward

    American Academy of Neurology

    Parkinson's Disease: Parkinson's Disease Medical and Surgical Treatment Options Reviewed

    All patients with a diagnosis of Parkinson's disease (or caregiver(s), as appropriate) who had the Parkinson's disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least annually

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 294

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    All patients with a diagnosis of Parkinson's disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 290

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Neurology

    Primary Measure Steward

    American Academy of Neurology

    Parkinson's Disease: Rehabilitative Therapy Options

    All patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 293

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 358

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Surgery
    • Orthopedic Surgery
    • Otolaryngology
    • Thoracic Surgery
    • Urology
    • Plastic Surgery

    Primary Measure Steward

    American College of Surgeons

    Patients with Metastatic Colorectal Cancer and KRAS 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 KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1860
    Quality ID: 452

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Pediatric Kidney Disease: Adequacy of Volume Management

    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) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 327

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Renal Physicians Association

    Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1667
    Quality ID: 328

    NQS Domain

    Effective Clinical Care

    Measure Type

    Intermediate Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 428

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 429

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    Primary Measure Steward

    American Urogynecologic Society

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2063
    Quality ID: 422

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Obstetrics/Gynecology

    Primary Measure Steward

    American Urogynecologic Society

    Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy

    Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0465
    Quality ID: 423

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Society for Vascular Surgeons

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0268
    Quality ID: 021

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • General Surgery
    • Orthopedic Surgery
    • Otolaryngology
    • Thoracic Surgery
    • Plastic Surgery

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0239
    Quality ID: 023

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • General Surgery
    • Orthopedic Surgery
    • Otolaryngology
    • Thoracic Surgery
    • Plastic Surgery

    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 recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2671
    Quality ID: 424

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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 a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0071
    Quality ID: 442

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    Photodocumentation of Cecal Intubation

    The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 425

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    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.

    Measure Number

    eMeasure ID: CMS127v5
    eMeasure NQF: N/A
    NQF: 0043
    Quality ID: 111

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • Preventive Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)

    Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 426

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Anesthesiology

    Primary Measure Steward

    American Society of Anesthesiologists

    Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

    Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 427

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Anesthesiology

    Primary Measure Steward

    American Society of Anesthesiologists

    Pregnant women that had HBsAg testing

    This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy

    Measure Number

    eMeasure ID: CMS158v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 369

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    Primary Measure Steward

    OptumInsight

    Preoperative Diagnosis of Breast Cancer

    The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 263

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    American Society of Breast Surgeons

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 076

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Anesthesiology
    • 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 or intraoperatively

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 430

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    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 six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

    Measure Number

    eMeasure ID: CMS69v5
    eMeasure NQF: N/A
    NQF: 0421
    Quality ID: 128

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • Gastroenterology
    • General Surgery
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: CMS147v6
    eMeasure NQF: N/A
    NQF: 0041
    Quality ID: 110

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • Internal Medicine
    • Obstetrics/Gynecology
    • Preventive Medicine
    • General Practice/Family Medicine
    • Pediatrics

    Primary Measure Steward

    Physician Consortium for Performance Improvement

    Preventive Care and Screening: Screening for Clinical 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

    Measure Number

    eMeasure ID: CMS2v6
    eMeasure NQF: N/A
    NQF: 0418
    Quality ID: 134

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Mental/Behavioral Health
    • General Practice/Family Medicine
    • Pediatrics

    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

    Measure Number

    eMeasure ID: CMS22v5
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 317

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • EHR
    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • Internal Medicine
    • Anesthesiology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery
    • General Practice/Family Medicine

    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 cessation counseling intervention if identified as a tobacco user

    Measure Number

    eMeasure ID: CMS138v5
    eMeasure NQF: N/A
    NQF: 0028
    Quality ID: 226

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • Internal Medicine
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery
    • General Practice/Family Medicine

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 2152
    Quality ID: 431

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • Emergency Medicine
    • Gastroenterology
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Mental/Behavioral Health
    • General Practice/Family Medicine

    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.

    Measure Number

    eMeasure ID: CMS74v6
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 379

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Pediatrics

    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

    Measure Number

    eMeasure ID: CMS143v5
    eMeasure NQF: N/A
    NQF: 0086
    Quality ID: 012

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • EHR
    • Registry

    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 12 months

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0563
    Quality ID: 141

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Ophthalmology

    Primary Measure Steward

    American Academy of Ophthalmology

    Proportion Admitted to Hospice for less than 3 days

    Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0216
    Quality ID: 457

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life

    Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0213
    Quality ID: 455

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Proportion Not Admitted To Hospice

    Proportion of patients who died from cancer not admitted to hospice

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0215
    Quality ID: 456

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    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 1 month after surgery

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 432

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Obstetrics/Gynecology

    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 1 month after surgery

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 433

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Obstetrics/Gynecology

    Primary Measure Steward

    American Urogynecologic Society

    Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair

    Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 434

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Obstetrics/Gynecology

    Primary Measure Steward

    American Urogynecologic Society

    Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life

    Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0211
    Quality ID: 454

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Proportion Receiving Chemotherapy in the Last 14 Days of Life

    Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0210
    Quality ID: 453

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Prostate Cancer: Adjuvant Hormonal 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 adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0390
    Quality ID: 104

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Urology

    Primary Measure Steward

    American Urological Association Education and Research

    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

    Measure Number

    eMeasure ID: CMS129v6
    eMeasure NQF: N/A
    NQF: 0389
    Quality ID: 102

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    • General Oncology
    • Radiation Oncology
    • Urology

    Primary Measure Steward

    Physician Consortium for Performance Improvement

    Psoriasis: Clinical Response to Oral Systemic or Biologic Medications

    Percentage of psoriasis patients receiving oral systemic or biologic 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 410

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Dermatology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 435

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Neurology

    Primary Measure Steward

    American Academy of Neurology

    Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients

    This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1855
    Quality ID: 251

    NQS Domain

    Effective Clinical Care

    Measure Type

    Structure

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Pathology

    Primary Measure Steward

    College of American Pathologists

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 436

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Diagnostic Radiology

    Primary Measure Steward

    American College of Radiology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1853
    Quality ID: 250

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • General Oncology
    • Pathology

    Primary Measure Steward

    College of American Pathologists

    Radiology: Exposure Dose or Time 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)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 145

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Diagnostic 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"

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0508
    Quality ID: 146

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0509
    Quality ID: 225

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Structure

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0507
    Quality ID: 195

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Diagnostic Radiology

    Primary Measure Steward

    American College of Radiology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 344

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Interventional Radiology
    • 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 260

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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 Die While in Hospital

    Percent of patients undergoing endovascular repair of small or moderate infrarenal abdominal aortic aneurysms (AAA) that die while in the hospital

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1534
    Quality ID: 347

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 259

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Interventional Radiology
    • Vascular Surgery

    Primary Measure Steward

    Society for Vascular Surgeons

    Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive

    Percentage of patients undergoing open repair of small or moderate abdominal aortic aneurysms (AAA) who are discharged alive

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1523
    Quality ID: 417

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Society for Vascular Surgeons

    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)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 258

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Vascular Surgery

    Primary Measure Steward

    Society for Vascular Surgeons

    Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)

    Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1543
    Quality ID: 345

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Interventional Radiology
    • Vascular Surgery

    Primary Measure Steward

    Society for Vascular Surgeons

    Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA)

    Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1540
    Quality ID: 346

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 437

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 261

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Audiology Quality Consortium

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 179

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 178

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 180

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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 and classification of disease activity within 12 months

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 177

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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 have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 176

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Rheumatology

    Primary Measure Steward

    American College of Rheumatology

    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)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 255

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Emergency Medicine

    Primary Measure Steward

    American College of Emergency Physicians

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0119
    Quality ID: 445

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 343

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0046
    Quality ID: 039

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Preventive Medicine

    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 who undergo a sentinel lymph node (SLN) procedure

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 264

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 279

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    American Academy of Sleep Medicine

    Sleep Apnea: Assessment of Sleep Symptoms

    Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 276

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    American Academy of Sleep Medicine

    Sleep Apnea: Positive Airway Pressure Therapy Prescribed

    Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 278

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 277

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    American Academy of Sleep Medicine

    Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

    Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1519
    Quality ID: 257

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    Primary Measure Steward

    Society for Vascular Surgeons

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 438

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • CMS Web Interface
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Cardiology
    • General Practice/Family Medicine

    Primary Measure Steward

    Centers for Medicare & Medicaid Services

    Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy

    Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed antithrombotic therapy at discharge

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 032

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Hospitalists
    • Neurology

    Primary Measure Steward

    American Academy of Neurology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 187

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 357

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Surgery
    • Otolaryngology
    • Vascular Surgery
    • Plastic 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 402

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Allergy/Immunology
    • Internal Medicine
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Gastroenterology
    • General Surgery
    • General Oncology
    • Hospitalists
    • Neurology
    • Obstetrics/Gynecology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    • Mental/Behavioral Health
    • Plastic Surgery
    • General Practice/Family Medicine
    • Pediatrics

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 353

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 352

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    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., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 350

    NQS Domain

    Communication and Care Coordination

    Measure Type

    Process

    High Priority Measure

    Yes

    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)

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 351

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    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

    Proportion 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 1858
    Quality ID: 450

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • General Oncology

    Primary Measure Steward

    American Society of Clinical Oncology

    Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier

    Percentage of patients 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 337

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    • Dermatology
    • Rheumatology
    • General Practice/Family Medicine

    Primary Measure Steward

    American Academy of Dermatology

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: 0651
    Quality ID: 254

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 356

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 355

    NQS Domain

    Patient Safety

    Measure Type

    Outcome

    High Priority Measure

    Yes

    Data Submission Method

    • Registry

    Specialty Measure Set

    • 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 048

    NQS Domain

    Effective Clinical Care

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • 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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 050

    NQS Domain

    Person and Caregiver-Centered Experience and Outcomes

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • Claims
    • Registry

    Specialty Measure Set

    • Internal Medicine
    • Obstetrics/Gynecology
    • Urology
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    Use of High-Risk Medications in the Elderly

    Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.

    Measure Number

    eMeasure ID: CMS156v5
    eMeasure NQF: N/A
    NQF: 0022
    Quality ID: 238

    NQS Domain

    Patient Safety

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR
    • Registry

    Specialty Measure Set

    Primary Measure Steward

    National Committee for Quality Assurance

    Use of Imaging Studies for Low Back Pain

    Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.

    Measure Number

    eMeasure ID: CMS166v6
    eMeasure NQF: N/A
    NQF: 0052
    Quality ID: 312

    NQS Domain

    Efficiency and Cost Reduction

    Measure Type

    Process

    High Priority Measure

    Yes

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Orthopedic Surgery
    • Physical Medicine
    • General Practice/Family Medicine

    Primary Measure Steward

    National Committee for Quality Assurance

    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

    Measure Number

    eMeasure ID: N/A
    eMeasure NQF: N/A
    NQF: N/A
    Quality ID: 420

    NQS Domain

    Effective Clinical Care

    Measure Type

    Outcome

    High Priority Measure

    No

    Data Submission Method

    • Registry

    Specialty Measure Set

    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

    Measure Number

    eMeasure ID: CMS155v5
    eMeasure NQF: N/A
    NQF: 0024
    Quality ID: 239

    NQS Domain

    Community/Population Health

    Measure Type

    Process

    High Priority Measure

    No

    Data Submission Method

    • EHR

    Specialty Measure Set

    • Pediatrics

    Primary Measure Steward

    National Committee for Quality Assurance