Download:
pdf |
pdf2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
The Physician Quality Reporting System (Physician Quality Reporting) measures were developed by various organizations for
2012. The following is a list of each measure, the measure developer, method of reporting available and contact information. Questions
regarding the construct of a measure or its intent should be referred to the measure developer/contact as outlined in Appendix II (on
page 33). Please note that gaps in measure numbering reflect retired 2007, 2008, 2009, 2010, and 2011 measures that are not
included in 2012. This measure list is intended as a summary list to assist eligible professionals initially reviewing the measures and
should not be used as a replacement for the measure specifications, which contain detailed reporting and coding instructions. A list of
Physician Quality Reporting Measure Specifications and where they can be found on the CMS website is listed in Appendix I (on page
32).
NQF
Measure
Reporting
#
Measure Title & Descriptiona
#
Developer Options/Methods
1.
0059
GPRO
DM-2
2.
0064
GPRO
DM-5
3.
0061
GPRO
DM-3
5.
0081
GPRO
HF-7
6.
0067
GPRO
CAD-1
7.
Version 6.2
0070
Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most
recent hemoglobin A1c greater than 9.0%
Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most
recent LDL-C level in control (less than 100 mg/dL)
Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most
recent blood pressure in control (less than 140/90 mmHg)
Heart Failure: 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
Coronary Artery Disease (CAD): Antiplatelet Therapy
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease
seen within a 12 month period who were prescribed aspirin or clopidogrel
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 prior MI OR a current or prior LVEF < 40%
who were prescribed beta-blocker therapy
NCQA
NCQA
NCQA
b
b
b
Claims, Registry , EHR ,
DM Measures Group (C/R),
c
GPRO ,
Cardiovascular Prevention
Measures Group (C/R)
b
b
Claims, Registry , EHR ,
DM Measures Group (C/R),
c
GPRO
b
AMAPCPI/ACCF/
AHA
b
Claims, Registry , EHR ,
DM Measures Group (C/R),
c
GPRO
b
Registry , EHR ,
HF Measures Group (R),
c
GPRO
b
AMAPCPI/ACCF/
AHA
b
Claims, Registry , EHR ,
CAD Measures Group (R),
c
GPRO
b
Registry , EHR
b
AMAPCPI/ACCF/
AHA
12/23/2011
Page 1 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
NQF
#
8.
0083
GPRO
HF-6
9.
10.
0105
0246
12.
0086
14.
0087
18.
19.
Version 6.2
0088
0089
Measure Title & Descriptiona
Heart Failure: 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 betablocker therapy either within a 12 month period when seen in the outpatient setting or at
each hospital discharge
Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase
for Patients with MDD
Percentage of patients aged 18 years and older diagnosed with new episode of MDD and
documented as treated with antidepressant medication during the entire 84-day (12-week)
acute treatment phase
Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic
Resonance Imaging (MRI) Reports
Percentage of final reports for CT or MRI studies of the brain performed either:
• In the hospital within 24 hours of arrival, OR
• In an outpatient imaging center to confirm initial diagnosis of stroke, transient
ischemic attack (TIA) or intracranial hemorrhage
For patients aged 18 years and older with either a diagnosis of ischemic stroke, TIA or
intracranial hemorrhage OR at least one documented symptom consistent with ischemic
stroke, TIA or intracranial hemorrhage that includes documentation of the presence or
absence of each of the following: hemorrhage, mass lesion and acute infarction
Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
Percentage of patients aged 18 years and older with a diagnosis of POAG who have an
optic nerve head evaluation during one or more office visits within 12 months
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Percentage of patients aged 50 years and older with a diagnosis of 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
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
Diabetic Retinopathy: Communication with the Physician Managing On-going
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 on-going care of the patient with diabetes mellitus
regarding the findings of the macular or fundus exam at least once within 12 months
Measure
Developer
Reporting
Options/Methods
b
AMAPCPI/ACCF/
AHA
b
Registry , EHR ,
HF Measures Group (R),
c
GPRO
b
Claims, Registry , EHR
b
NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/NCQA
Claims, Registry , EHR
b
b
Claims, Registry
AMAPCPI/NCQA
b
b
b
b
Claims, Registry , EHR
AMAPCPI/NCQA
Claims, Registry , EHR
AMAPCPI/NCQA
12/23/2011
Page 2 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
20.
21.
22.
23.
24.
28.
30.
Version 6.2
NQF
#
0270
0268
0271
0239
0045
0092
0269
Measure Title & Descriptiona
Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic parenteral antibiotics, who have an order for prophylactic
parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two
hours), prior to the surgical incision (or start of procedure when no incision is required)
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 cefazolin OR cefuroxime for antimicrobial prophylaxis
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac
Procedures)
Percentage of non-cardiac surgical patients aged 18 years and older undergoing
procedures with the indications for prophylactic parenteral antibiotics AND who received a
prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic
parenteral antibiotics within 24 hours of surgical end time
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in
ALL Patients)
Percentage of patients aged 18 years and older undergoing procedures for which 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
Osteoporosis: Communication with the Physician Managing On-going Care PostFracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older treated for a hip, spine or distal radial
fracture with documentation of communication with the physician managing the patient’s
on-going care that a fracture occurred and that the patient was or should be tested or
treated for osteoporosis
Aspirin at Arrival for Acute Myocardial Infarction (AMI)
Percentage of patients, regardless of age, with an emergency department discharge
diagnosis of AMI who had documentation of receiving aspirin within 24 hours before
emergency department arrival or during emergency department stay
Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
Percentage of surgical patients aged 18 years and older who receive an anesthetic when
undergoing procedures with the indications for prophylactic parenteral antibiotics for whom
administration of the prophylactic parenteral antibiotic ordered has been initiated within one
hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of
procedure when no incision is required)
Measure
Developer
Reporting
Options/Methods
b
AMAPCPI/NCQA
Claims, Registry ,
Periop Measures Group (C/R)
b
Claims, Registry ,
Periop Measures Group (C/R)
AMAPCPI/NCQA
b
Claims, Registry ,
Periop Measures Group (C/R)
AMAPCPI/NCQA
b
Claims, Registry ,
Periop Measures Group (C/R)
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
12/23/2011
Page 3 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
31.
NQF
#
0240
32.
0325
33.
0241
35.
36.
39.
40.
0243
0244
0046
0048
41.
0049
43.
0134
Version 6.2
Measure Title & Descriptiona
Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for
Ischemic Stroke or Intracranial Hemorrhage
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or
intracranial hemorrhage who were administered DVT prophylaxis by end of hospital day
two
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
Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial
Fibrillation (AF) at Discharge
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or
transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial
fibrillation who were prescribed an anticoagulant at discharge
Stroke and Stroke Rehabilitation: Screening for Dysphagia
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or
intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for
whom a dysphagia screening was performed prior to PO intake in accordance with a
dysphagia screening tool approved by the institution in which the patient is receiving care
Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or
intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services
were ordered at or prior to inpatient discharge OR documentation that no rehabilitation
services are indicated at or prior to inpatient discharge
Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who have a central dual-energy Xray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men
and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal
radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or
performed or pharmacologic therapy prescribed
Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who
were prescribed pharmacologic therapy within 12 months
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 using
an IMA graft
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/NCQA
Claims, Registry
b
Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/NCQA
b
Claims, Registry , EHR ,
Prev Care Measures Group
(C/R)
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/NCQA
Claims, Registry
b
STS
Claims, Registry ,
CABG Measures Group (R)
12/23/2011
Page 4 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
44.
45.
46.
NQF
#
0236
0637
0097
GPRO
Care-1
47.
48.
49.
50.
51.
52.
GPRO
COPD-1
Version 6.2
0326
0098
0099
0100
0091
0102
Measure Title & Descriptiona
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with
Isolated CABG Surgery
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who
received a beta-blocker within 24 hours prior to surgical incision
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures)
Percentage of cardiac surgical patients aged 18 years and older undergoing procedures
with the indications for prophylactic antibiotics AND who received a prophylactic antibiotic,
who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical
end time
Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility
Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g.,
hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following
discharge in the office by the physician providing on-going care who had a reconciliation of
the discharge medications with the current medication list in the medical record
documented
Advance Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or
surrogate decision maker documented in the medical record or documentation in the
medical record that an advance care plan was discussed but the patient did not wish or was
not able to name a surrogate decision maker or provide an advance care plan
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
Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65
Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary
incontinence whose urinary incontinence was characterized at least once within 12 months
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
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
Percentage of patients aged 18 years and older with a diagnosis of COPD who had
spirometry evaluation results documented
Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy
Percentage of patients aged 18 years and older with a diagnosis of COPD and who have
an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled
bronchodilator
Measure
Developer
Reporting
Options/Methods
b
CMS/QIP
Claims, Registry ,
CABG Measures Group (R)
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry , GPRO
c
AMAPCPI/NCQA
b
b
b
b
Claims, Registry , EHR
AMAPCPI/NCQA
AMAPCPI/NCQA
Claims, Registry , EHR ,
Prev Care Measures Group
(C/R)
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
AMA-PCPI
Claims, Registry ,
COPD Measures Group (C/R)
b
AMA-PCPI
Claims, Registry ,
COPD Measures Group (C/R),
c
GPRO
12/23/2011
Page 5 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
53.
54.
NQF
#
0047
0090
55.
0093
56.
0232
57.
0094
58.
0095
59.
0096
64.
0001
65.
0069
66.
Version 6.2
0002
Measure Title & Descriptiona
Asthma: Pharmacologic Therapy for Persistent Asthma
Percentage of patients aged 5 through 50 years with a diagnosis of persistent asthma and
at least one medical encounter for asthma during the measurement year who were
prescribed long-term control medication
Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for NonTraumatic Chest Pain
Percentage of patients aged 40 years and older with an emergency department discharge
diagnosis of non-traumatic chest pain who had a 12-lead ECG performed
Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope
Percentage of patients aged 60 years and older with an emergency department discharge
diagnosis of syncope who had a 12-lead ECG performed
Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs
Percentage of patients aged 18 years and older with a diagnosis of community-acquired
bacterial pneumonia with vital signs documented and reviewed
Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of
Oxygen Saturation
Percentage of patients aged 18 years and older with a diagnosis of community-acquired
bacterial pneumonia with oxygen saturation documented and reviewed
Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of
Mental Status
Percentage of patients aged 18 years and older with a diagnosis of community-acquired
bacterial pneumonia with mental status assessed
Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic
Percentage of patients aged 18 years and older with a diagnosis of community-acquired
bacterial pneumonia with an appropriate empiric antibiotic prescribed
Asthma: Assessment of Asthma Control
Percentage of patients aged 5 through 50 years with a diagnosis of asthma who were
evaluated at least once for asthma control (comprising asthma impairment and asthma risk)
Treatment for Children with Upper Respiratory Infection (URI): Avoidance of
Inappropriate Use
Percentage of children aged 3 months through 18 years with a diagnosis of URI who were
not prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date
of service
Appropriate Testing for Children with Pharyngitis
Percentage of children aged 2 through 18 years with a diagnosis of pharyngitis, who were
prescribed an antibiotic and who received a group A streptococcus (strep) test for the
episode
Measure
Developer
Reporting
Options/Methods
b
AMAPCPI/NCQA
b
Claims, Registry , EHR ,
Asthma Measures Group
(C/R)
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/NCQA
Claims, Registry
b
AMAPCPI/NCQA
Claims, Registry ,
CAP Measures Group (C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
CAP Measures Group (C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
CAP Measures Group (C/R)
b
AMAPCPI/NCQA
AMAPCPI/NCQA
Claims, Registry ,
CAP Measures Group (C/R)
b
b
b
b
Claims, Registry , EHR ,
Asthma Measures Group
(C/R)
b
Claims, Registry
NCQA
Claims, Registry , EHR
NCQA
12/23/2011
Page 6 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
67.
68.
69.
NQF
#
0377
0378
0380
70.
0379
71.
0387
72.
76.
81.
82.
Version 6.2
0385
0464
0323
0321
Measure Title & Descriptiona
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 MDS or an acute
leukemia who had baseline cytogenetic testing performed on bone marrow
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 MDS who are receiving
erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin
therapy
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
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
Percentage of patients aged 18 years and older with a diagnosis of CLL who had baseline
flow cytometry studies performed
Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone
Receptor (ER/PR) Positive Breast Cancer
Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or
PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during
the 12-month reporting period
Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer
who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have
previously received adjuvant chemotherapy within the 12-month reporting period
Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous
Catheter (CVC) Insertion Protocol
Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was
inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile
gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2%
chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current
guideline)] followed
Adult Kidney Disease: Hemodialysis Adequacy: Solute
Percentage of calendar months within a 12-month period during which patients aged 18
years and older with a diagnosis of ESRD receiving hemodialysis three times a week who
have a spKt/V ≥ 1.2
Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute
Percentage of patients aged 18 years and older with a diagnosis of ESRD receiving
peritoneal dialysis who have a total Kt/V ≥ 1.7 per week measured once every 4 months
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
AMAPCPI/ASH
b
Claims, Registry
AMAPCPI/ASH
b
Claims, Registry
AMAPCPI/ASH
b
AMAPCPI/ASH
Claims, Registry
b
b
b
b
Claims, Registry , EHR
AMA-PCPI/
ASCO/NCCN
Claims, Registry , EHR
AMA-PCPI/
ASCO/NCCN
b
Claims, Registry
AMA-PCPI
b
Registry
AMA-PCPI
b
Registry
AMA-PCPI
12/23/2011
Page 7 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
83.
84.
85.
86.
87.
89.
90.
91.
92.
NQF
#
0393
0395
0396
0397
0398
0401
0394
0653
AQA
adopted
93.
99.
Version 6.2
0654
0391
Measure Title & Descriptiona
Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C Viremia
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an
initial evaluation who had HCV RNA testing ordered or previously performed
Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who
are receiving antiviral treatment for whom quantitative HCV RNA testing was performed
within 6 months prior to initiation of antiviral treatment
Hepatitis C: HCV Genotype Testing Prior to Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who
are receiving antiviral treatment for whom HCV genotype testing was performed prior to
initiation of antiviral treatment
Hepatitis C: Antiviral Treatment Prescribed
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who
were prescribed at a minimum peginterferon and ribavirin therapy within the 12-month
reporting period
Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who
are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at
no greater than 12 weeks from the initiation of antiviral treatment
Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were
counseled about the risks of alcohol use at least once within 12-months
Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy
Percentage of female patients aged 18 through 44 years and all men aged 18 years and
older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were
counseled regarding contraception prior to the initiation of treatment
Acute Otitis Externa (AOE): Topical Therapy
Percentage of patients aged 2 years and older with a diagnosis of AOE who were
prescribed topical preparations
Acute Otitis Externa (AOE): Pain Assessment
Percentage of patient visits for those patients aged 2 years and older with a diagnosis of
AOE with assessment for auricular or periauricular pain
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
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
Developer
Reporting
Options/Methods
b
Registry
AMA-PCPI
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group
(C/R)
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMAPCPI/CAP
12/23/2011
Page 8 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
100.
102.
104.
105.
106.
107.
108.
109.
Version 6.2
NQF
#
0392
0389
0390
0388
0103
0104
0054
0050
Measure Title & Descriptiona
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
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 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
Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of
recurrence receiving external beam radiotherapy to the prostate who were prescribed
adjuvant hormonal therapy (GnRH agonist or antagonist)
Prostate Cancer: Three-Dimensional (3D) Radiotherapy
Percentage of patients, regardless of age, with a diagnosis of clinically localized prostate
cancer receiving external beam radiotherapy as a primary therapy to the prostate with or
without nodal irradiation (no metastases; no salvage therapy) who receive threedimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy
(IMRT)
Major Depressive Disorder (MDD): Diagnostic Evaluation
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode
of MDD who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent
episode was identified during the measurement period
Major Depressive Disorder (MDD): Suicide Risk Assessment
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode
of MDD who had a suicide risk assessment completed at each visit during the
measurement period
Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD)
Therapy
Percentage of patients aged 18 years and older who were diagnosed with RA and were
prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA
with assessment for function and pain
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
AMAPCPI/CAP
b
Claims, Registry , EHR
b
AMA-PCPI
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMA-PCPI
b
NCQA
Claims, Registry ,
RA Measures Group (C/R)
b
Claims, Registry
AMA-PCPI
12/23/2011
Page 9 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
110.
NQF
#
0041
GPRO
Prev-7
111.
0043
GPRO
Prev-8
112.
0031
GPRO
Prev-5
113.
0034
GPRO
Prev-6
116.
117.
0058
0055
GPRO
DM-7
118.
0066
GPRO
CAD-7
119.
Version 6.2
0062
Measure Title & Descriptiona
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and
March 31 of the one-year measurement period who received an influenza immunization OR
who reported previous receipt of an influenza immunization
Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and
Older
Percentage of patients aged 65 years and older who have ever received a pneumococcal
vaccine
Preventive Care and Screening: Screening Mammography
Percentage of women aged 40 through 69 years who had a mammogram to screen for
breast cancer within 24 months
Preventive Care and Screening: Colorectal Cancer Screening
Percentage of patients aged 50 through 75 years who received the appropriate colorectal
cancer screening
Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate
Use
Percentage of adults aged 18 through 64 years with a diagnosis of acute bronchitis who
were not prescribed or dispensed an antibiotic prescription on or within 3 days of the initial
date of service
Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who
had a dilated eye exam
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes
and/or Left Ventricular Systolic Dysfunction (LVSD)
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 LVEF < 40%
who were prescribed ACE inhibitor or ARB therapy
Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for
Nephropathy in Diabetic Patients
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine
protein screening or medical attention for nephropathy during at least one office visit within
12 months
Measure
Developer
AMA-PCPI
NCQA
NCQA
NCQA
Reporting
Options/Methods
b
b
b
b
b
b
Claims, Registry , EHR ,
COPD Measures Group (C/R),
Prev Care Measures Group
(C/R),
CKD Measures Group (C/R),
c
GPRO
b
b
Claims, Registry , EHR ,
COPD Measures Group (C/R),
Prev Care Measures Group
c
(C/R), GPRO
Claims, Registry , EHR ,
Prev Care Measures Group
c
(C/R), GPRO
Claims, Registry , EHR ,
Prev Care Measures Group
c
(C/R), GPRO
b
Claims, Registry
NCQA
b
NCQA
b
Claims, Registry , EHR ,
DM Measures Group (C/R),
c
GPRO
b
Registry , GPRO
c
AMAPCPI/ACCF/
AHA
b
b
Claims, Registry , EHR ,
DM Measures Group (C/R)
NCQA
12/23/2011
Page 10 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
121.
NQF
#
AQA
adopted
122.
AQA
adopted
123.
AQA
adopted
124.
0488
125.
0486
126.
0417
127.
128.
GPRO
Prev-9
Version 6.2
0416
0421
Measure Title & Descriptiona
Adult Kidney Disease: Laboratory Testing (Lipid Profile)
Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4, or 5,
not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed
at least once within a 12-month period
Adult Kidney Disease: Blood Pressure Management
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of
CKD (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) and documented
proteinuria with a blood pressure < 130/80 mmHg OR ≥ 130/80 mmHg with a documented
plan of care
Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) Hemoglobin Level > 12.0 g/dL
Percentage of calendar months within a 12-month period during which a Hemoglobin level
is measured for patients aged 18 years and older with a diagnosis of advanced Chronic
Kidney Disease (CKD) (stage 4 or 5, not receiving Renal Replacement Therapy [RRT]) or
End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are
also receiving ESA therapy AND have a Hemoglobin level > 12.0 g/dL
Health Information Technology (HIT): Adoption/Use of Electronic Health Records
(EHR)
Documents whether provider has adopted and is using health information technology. To
report this measure, the eligible professional must have adopted and be using a certified,
Physician Quality Reporting System qualified or other acceptable EHR system
Refer to the Electronic Prescribing (eRx) Incentive Program
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
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
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Percentage of patients aged 18 years and older with a calculated BMI in the past six
months or during the current visit documented in the medical record AND if the most recent
BMI is outside of normal parameters, a follow-up plan is documented
Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64 years BMI ≥
18.5 and < 25
Measure
Developer
Reporting
Options/Methods
b
AMA-PCPI
Claims, Registry ,
CKD Measures Group (C/R)
b
Claims, Registry ,
CKD Measures Group (C/R)
AMA-PCPI
b
Claims, Registry ,
CKD Measures Group (C/R)
AMA-PCPI
b
Claims, Registry
CMS/QIP
CMS/QIP
--b
Claims, Registry
APMA
b
Claims, Registry
APMA
b
b
Claims, Registry , EHR ,
Prev Care Measures Group
c
(C/R), GPRO
CMS/QIP
12/23/2011
Page 11 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
130.
131.
134.
137.
138.
140.
141.
Version 6.2
NQF
#
0419
0420
0418
0650
0561
0566
0563
Measure Title & Descriptiona
Documentation of Current Medications in the Medical Record
Percentage of specified visits for patients aged 18 years and older for which the eligible
professional attests to documenting a list of current medications to the best of his/her
knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals,
vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name,
dosage, frequency and route
Pain Assessment and Follow-Up
Percentage of patients aged 18 years and older with documentation of a pain assessment
through discussion with the patient including the use of a standardized tool(s) on each visit
AND documentation of a follow-up plan when pain is present
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up
Plan
Percentage of patients aged 12 years and older screened for clinical depression using an
age appropriate standardized tool AND follow-up plan documented
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
Melanoma: Coordination of Care
Percentage of patient visits, regardless of patient 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
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
Percentage of patients aged 50 years and older with a diagnosis of AMD and/or their
caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AgeRelated Eye Disease Study (AREDS) formulation for preventing progression of AMD
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 POAG whose glaucoma
treatment has not failed (the most recent IOP was reduced by at least 15% from the preintervention level) OR if the most recent IOP was not reduced by at least 15% from the preintervention level, a plan of care was documented within 12 months
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
CMS/QIP
b
Claims, Registry
CMS/QIP
b
Claims, Registry
CMS/QIP
b
Registry
AMAPCPI/NCQA
b
Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
12/23/2011
Page 12 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
142.
143.
144.
NQF
#
0051
0384
0383
145.
0510
146.
0508
147.
148.
149.
150.
Version 6.2
0511
0322
0319
0314
Measure Title & Descriptiona
Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-theCounter (OTC) Medications
Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA
with an assessment for use of anti-inflammatory or analgesic OTC medications
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
Oncology: Medical and Radiation – Plan of Care for Pain
Percentage of patient visits, regardless of patient 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
Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
Percentage of final reports for procedures using fluoroscopy that include documentation of
radiation exposure or exposure time
Radiology: Inappropriate Use of “Probably Benign” Assessment Category in
Mammography Screening
Percentage of final reports for screening mammograms that are classified as “probably
benign”
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
Back Pain: Initial Visit
The percentage of patients aged 18 through 79 years with a diagnosis of back pain or
undergoing back surgery who had back pain and function assessed during the initial visit to
the clinician for the episode of back pain
Back Pain: Physical Exam
Percentage of patients aged 18 through 79 years with a diagnosis of back pain or
undergoing back surgery who received a physical examination at the initial visit to the
clinician for the episode of back pain
Back Pain: Advice for Normal Activities
The percentage of patients aged 18 through 79 years with a diagnosis of back pain or
undergoing back surgery who received advice for normal activities at the initial visit to the
clinician for the episode of back pain
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
AMA-PCPI
b
Registry
AMA-PCPI
b
Registry
AMA-PCPI
b
AMAPCPI/NCQA
Claims, Registry
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMA-PCPI
NCQA
NCQA
NCQA
Back Pain Measures Group
(C/R)
Back Pain Measures Group
(C/R)
Back Pain Measures Group
(C/R)
12/23/2011
Page 13 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
151.
154.
NQF
#
0313
AQA
adopted
155.
AQA
adopted
156.
157.
158.
0382
0455
0466
159.
0404
160.
0405
161.
Version 6.2
0406
Measure Title & Descriptiona
Back Pain: Advice Against Bed Rest
The percentage of patients aged 18 through 79 years with a diagnosis of back pain or
undergoing back surgery who received advice against bed rest lasting four days or longer
at the initial visit to the clinician for the episode of back pain
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls who had a risk
assessment for falls completed within 12 months
Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls who had a plan of
care for falls documented within 12 months
Oncology: Radiation Dose Limits to Normal Tissues
Percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer
receiving 3D conformal radiation therapy with 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
Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal
Cancer Resection
Percentage of surgical patients aged 18 years and older undergoing resection for lung or
esophageal cancer who had clinical staging provided prior to surgery
Carotid Endarterectomy: Use of Patch During Conventional Carotid Endarterectomy
Percentage of patients aged 18 years and older undergoing conventional (non-eversion)
carotid endarterectomy (CEA) who undergo patch closure of the arteriotomy
HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a
CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 years and older with a diagnosis of HIV/AIDS and CD4+ cell
3
count < 200 cells/mm who were prescribed PCP prophylaxis within 3 months of low CD4+
cell count
HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent
Antiretroviral Therapy
Percentage of patients with a diagnosis of HIV/AIDS aged 13 years and older: who have a
3
history of a nadir CD4+ cell count below 350/mm or who have a history of an AIDSdefining condition, regardless of CD4+ cell count; or who are pregnant, regardless of CD4+
cell count or age, who were prescribed potent antiretroviral therapy
Measure
Developer
NCQA
Reporting
Options/Methods
Back Pain Measures Group
(C/R)
b
AMAPCPI/NCQA
Claims, Registry
b
AMAPCPI/NCQA
Claims, Registry
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
STS
b
Claims, Registry
SVS
b
AMAPCPI/NCQA
Registry ,
HIV/AIDS Measures Group (R)
b
AMAPCPI/NCQA
Registry ,
HIV/AIDS Measures Group (R)
b
Registry ,
HIV/AIDS Measures Group (R)
AMAPCPI/NCQA
12/23/2011
Page 14 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
162.
163.
NQF
#
0407
0056
GPRO
DM-8
164.
165.
166.
167.
168.
169.
170.
171.
Version 6.2
0129
0130
0131
0114
0115
0116
0117
0118
Measure Title & Descriptiona
HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who are
receiving potent antiretroviral therapy, who have a viral load below limits of quantification
after at least 6 months of potent antiretroviral therapy or patients whose viral load is not
below limits of quantification after at least 6 months of potent antiretroviral therapy and
have documentation of a plan of care
Diabetes Mellitus: Foot Exam
The percentage of patients aged 18 through 75 years with diabetes who had a foot
examination
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who
require intubation > 24 hours
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)
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
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
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
Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who
were discharged on antiplatelet medication
Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who
were discharged on beta-blockers
Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who
were discharged on a statin or other lipid-lowering regimen
Measure
Developer
Reporting
Options/Methods
b
Registry ,
HIV/AIDS Measures Group (R)
AMAPCPI/NCQA
b
b
NCQA
Claims, Registry , EHR ,
DM Measures Group (C/R),
c
GPRO
STS
Registry ,
CABG Measures Group (R)
b
b
STS
Registry ,
CABG Measures Group (R)
b
STS
Registry ,
CABG Measures Group (R)
b
STS
Registry ,
CABG Measures Group (R)
b
Registry ,
CABG Measures Group (R)
STS
b
STS
Registry ,
CABG Measures Group (R)
STS
Registry ,
CABG Measures Group (R)
STS
Registry ,
CABG Measures Group (R)
b
b
12/23/2011
Page 15 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
172.
173.
NQF
#
0259
AQA
adopted
176.
AQA
adopted
177.
AQA
adopted
178.
AQA
adopted
179.
AQA
adopted
180.
AQA
adopted
181.
AQA
adopted
182.
AQA
adopted
183.
Version 6.2
0399
Measure Title & Descriptiona
Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement
of Autogenous Arterial Venous (AV) Fistula
Percentage of patients aged 18 years and older with a diagnosis of advanced Chronic
Kidney Disease (CKD) (stage 4 or 5) or End Stage Renal Disease (ESRD) requiring
hemodialysis vascular access documented by surgeon to have received autogenous AV
fistula
Preventive Care and Screening: Unhealthy Alcohol Use – Screening
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol
use using a systematic screening method within 24 months
Rheumatoid Arthritis (RA): Tuberculosis Screening
Percentage of patients aged 18 years and older with a diagnosis of 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 antirheumatic drug (DMARD)
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Percentage of patients aged 18 years and older with a diagnosis of RA who have an
assessment and classification of disease activity within 12 months
Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with a diagnosis of RA for whom a
functional status assessment was performed at least once within 12 months
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Percentage of patients aged 18 years and older with a diagnosis of RA who have an
assessment and classification of disease prognosis at least once within 12 months
Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of 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
Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with documentation of a screen for elder
maltreatment AND documented follow-up plan
Functional Outcome Assessment
Percentage of patients aged 18 years and older with documentation of a current functional
outcome assessment using a standardized functional outcome assessment tool AND
documentation of a care plan based on identified functional outcome deficiencies
Hepatitis C: Hepatitis A Vaccination in Patients with HCV
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who
received at least one injection of hepatitis A vaccine, or who have documented immunity to
hepatitis A
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
SVS
b
AMA-PCPI
b
Claims, Registry , EHR ,
Prev Care Measures Group
(C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
RA Measures Group (C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
RA Measures Group (C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
RA Measures Group (C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
RA Measures Group (C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
RA Measures Group (C/R)
b
Claims, Registry
CMS/QIP
b
Claims, Registry
CMS/QIP
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
12/23/2011
Page 16 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
184.
185.
186.
NQF
#
0400
0659
AQA
adopted
187.
188.
189.
190.
191.
Version 6.2
0437
N/A
N/A
N/A
0565
Measure Title & Descriptiona
Hepatitis C: Hepatitis B Vaccination in Patients with HCV
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who
received at least one injection of hepatitis B vaccine, or who have documented immunity to
hepatitis B
Endoscopy & Polyp Surveillance: 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 colonic polyp(s) in a previous colonoscopy, who had a follow-up interval of 3 or
more years since their last colonoscopy documented in the colonoscopy report
Chronic Wound Care: Use of Compression System in Patients with Venous Ulcers
Percentage of patients aged 18 years and older with a diagnosis of venous ulcer who were
prescribed compression therapy within the 12-month reporting period
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
Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity
of the Ear
Percentage of patients aged birth and older referred to a physician (preferably a physician
with training in disorders of the ear) for an otologic evaluation subsequent to an audiologic
evaluation after presenting with a congenital or traumatic deformity of the ear (internal or
external)
Referral for Otologic Evaluation for Patients with History of Active Drainage from the
Ear Within the Previous 90 Days
Percentage of patients aged birth and older who have disease of the ear and mastoid
processes referred to a physician (preferably a physician with training in disorders of the
ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with
a history of active drainage from the ear within the previous 90 days
Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly
Progressive Hearing Loss
Percentage of patients aged birth and older referred to a physician (preferably a physician
with training in disorders of the ear) for an otologic evaluation immediately following an
audiologic evaluation that verifies and documents sudden or rapidly progressive hearing
loss
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
Developer
Reporting
Options/Methods
b
AMA-PCPI
Claims, Registry ,
Hep C Measures Group (C/R)
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/NCQA
Claims, Registry
b
Registry
AHA/ASA/
TJC
b
Claims, Registry
AQC
b
Claims, Registry
AQC
b
Claims, Registry
AQC
b
AMAPCPI/NCQA
Registry , Cataract Measures
Group (R)
12/23/2011
Page 17 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
192.
193.
194.
195.
196.
197.
NQF
#
0564
0454
0386
0507
0065
0074
GPRO
CAD-2
198.
GPRO
HF-1
Version 6.2
0079
Measure Title & Descriptiona
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
Perioperative Temperature Management
Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures
under general or neuraxial anesthesia of 60 minutes duration or longer, except patients
undergoing cardiopulmonary bypass, for whom either active warming was used
intraoperatively for the purpose of maintaining normothermia, OR at least one body
temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit)
was recorded within the 30 minutes immediately before or the 15 minutes immediately after
anesthesia end time
Oncology: Cancer Stage Documented
Percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer
who are seen in the ambulatory setting who have a baseline AJCC cancer stage or
documentation that the cancer is metastatic in the medical record at least once within 12
months
Radiology: Stenosis Measurement in Carotid Imaging Reports
Percentage of final reports for all patients, regardless of age, 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
Coronary Artery Disease (CAD): Symptom and Activity Assessment
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease
seen within a 12 month period for whom there are documented results of an evaluation of
level of activity AND an evaluation of presence or absence of anginal symptoms in the
medical record
Coronary Artery Disease (CAD): Lipid Control
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease
seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who
have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C <
100 mg/dL, including at a minimum the prescription of a statin
Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment
Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom
the quantitative or qualitative result (of a recent or prior [any time in the past] LVEF
assessment) is documented within a 12 month period
Measure
Developer
Reporting
Options/Methods
b
Registry , Cataract Measures
Group (R)
AMAPCPI/NCQA
b
Claims, Registry
AMA-PCPI
b
Claims, Registry
AMAPCPI/ASCO
b
Claims, Registry
AMAPCPI/NCQA
b
AMAPCPI/ACCF/
AHA
Registry ,
CAD Measures Group (R)
b
AMAPCPI/ACCF/
AHA
b
Registry , EHR ,
CAD Measures Group (R),
c
GPRO
b
AMAPCPI/ACCF/
AHA
Registry ,
HF Measures Group (R),
c
GPRO
12/23/2011
Page 18 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
199.
NQF
#
0082
GPRO
HF-5
200.
0084
201.
0073
204.
0068
GPRO
IVD-2
205.
0409
206.
0413
207.
0415
208.
0410
209.
0445
210.
Version 6.2
0449
Measure Title & Descriptiona
Heart Failure: Patient Education
Percentage of patients aged 18 years and older with a diagnosis of heart failure who were
provided with patient education on disease management and health behavior changes
during one or more visit(s) within 12 months
Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation
Percentage of all patients aged 18 and older with a diagnosis of heart failure and
paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy
Ischemic Vascular Disease (IVD): Blood Pressure Management Control
Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) who
had most recent blood pressure in control (less than 140/90 mmHg)
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) with
documented use of aspirin or other antithrombotic
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom
chlamydia and gonorrhea screenings were performed at least once since the diagnosis of
HIV infection
HIV/AIDS: Screening for High Risk Sexual Behaviors
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were
screened for high risk sexual behaviors at least once within 12 months
HIV/AIDS: Screening for Injection Drug Use
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were
screened for injection drug use at least once within 12 months
HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were
screened for syphilis at least once within 12 months
Functional Communication Measure - Spoken Language Comprehension
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Spoken Language
Comprehension Functional Communication Measure
Functional Communication Measure - Attention
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Attention Functional
Communication Measure
Measure
Developer
Reporting
Options/Methods
GPRO
c
CMS/QIP
AMAPCPI/ACCF/A
HA
NCQA
NCQA
AMAPCPI/NCQA
EHR
b
b
b
b
b
Claims, Registry , EHR ,
IVD Measures Group (C/R)
Claims, Registry , EHR ,
IVD Measures Group (C/R),
Cardiovascular Prevention
Measures Group (C/R),
c
GPRO
b
Registry ,
HIV/AIDS Measures Group (R)
b
AMAPCPI/NCQA
Registry ,
HIV/AIDS Measures Group (R)
b
AMAPCPI/NCQA
Registry ,
HIV/AIDS Measures Group (R)
b
AMAPCPI/NCQA
Registry ,
HIV/AIDS Measures Group (R)
b
Registry
ASHA
b
Registry
ASHA
12/23/2011
Page 19 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
211.
212.
213.
214.
215.
216.
217.
218.
219.
Version 6.2
NQF
#
0448
0447
0446
0444
0442
0443
0422
0423
0424
Measure Title & Descriptiona
Functional Communication Measure - Memory
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Memory Functional
Communication Measure
Functional Communication Measure - Motor Speech
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Motor Speech Functional
Communication Measure
Functional Communication Measure - Reading
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Reading Functional
Communication Measure
Functional Communication Measure - Spoken Language Expression
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Spoken Language Expression
Functional Communication Measure
Functional Communication Measure - Writing
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Writing Functional
Communication Measure
Functional Communication Measure - Swallowing
Percentage of patients aged 16 years and older with a diagnosis of late effects of
cerebrovascular disease (CVD) that make progress on the Swallowing Functional
Communication Measure
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee
Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the knee in which the change in their Risk-Adjusted
Functional Status is measured
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip
Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the hip in which the change in their Risk-Adjusted
Functional Status is measured
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with
Lower Leg, Foot or Ankle Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the lower leg, foot or ankle in which the change in
their Risk-Adjusted Functional Status is measured
Measure
Developer
Reporting
Options/Methods
b
Registry
ASHA
b
Registry
ASHA
b
Registry
ASHA
b
Registry
ASHA
b
Registry
ASHA
b
Registry
ASHA
b
Registry
FOTO
b
Registry
FOTO
b
Registry
FOTO
12/23/2011
Page 20 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
220.
221.
222.
223.
224.
225.
226.
GPRO
Prev-10
NQF
#
0425
0426
0427
0428
0562
0509
0028
Measure Title & Descriptiona
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with
Lumbar Spine Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the lumbar spine in which the change in their RiskAdjusted Functional Status is measured
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with
Shoulder Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the shoulder in which the change in their RiskAdjusted Functional Status is measured
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with
Elbow, Wrist or Hand Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the elbow, wrist or hand in which the change in their
Risk-Adjusted Functional Status is measured
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck,
Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments
Percentage of patients aged 18 or older that receive treatment for a functional deficit
secondary to a diagnosis that affects the neck, cranium, mandible, thoracic spine, ribs, or
other general orthopedic impairment in which the change in their Risk-Adjusted Functional
Status is measured
Melanoma: Overutilization of Imaging Studies in Melanoma
Percentage of patients, regardless of age, with a current diagnosis of melanoma or a
history of melanoma, without signs or symptoms, seen for an office visit during the one-year
measurement period, for whom no diagnostic imaging studies were ordered
Radiology: Reminder System for Mammograms
Percentage of patients aged 40 years and older undergoing a screening mammogram
whose information is entered into a reminder system with a target due date for the next
mammogram
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
Developer
b
Registry
FOTO
b
Registry
FOTO
b
Registry
FOTO
b
Registry
FOTO
b
Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
AMA-PCPI
Version 6.2
Reporting
Options/Methods
b
Claims, Registry , EHR ,
CAD Measures Group (R),
COPD Measures Group (C/R),
HF Measures Group (R), IBD
Measures Group (R), IVD
Measures Group (C/R), Prev
Care Measures Group (C/R),
Cardiovascular Prevention
Measures Group (C/R),
c
GPRO
12/23/2011
Page 21 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
228.
NQF
#
N/A
GPRO
HF-2
231.
232.
233.
234.
235.
236.
N/A
N/A
0457
0458
0017
0018
GPRO
HTN-2
237.
Version 6.2
0013
Measure Title & Descriptiona
Heart Failure (HF): Left Ventricular Function (LVF) Testing
Percentage of patients 18 years and older with LVF testing performed during the
measurement period for patients hospitalized with a principal diagnosis of HF during the
reporting period
Asthma: Tobacco Use: Screening - Ambulatory Care Setting
Percentage of patients (or their primary caregiver) aged 5 through 50 years with a
diagnosis of asthma who were queried about tobacco use and exposure to second hand
smoke within their home environment at least once during the one-year measurement
period
Asthma: Tobacco Use: Intervention - Ambulatory Care Setting
Percentage of patients (or their primary caregiver) aged 5 through 50 years with a
diagnosis of asthma who were identified as tobacco users (patients who currently use
tobacco AND patients who do not currently use tobacco, but are exposed to second hand
smoke in their home environment) who received tobacco cessation intervention at least
once during the one-year measurement period
Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal
Cancer Resection
Percentage of patients aged 18 years and older undergoing resection for lung or
esophageal cancer who had performance status documented and reviewed within 2 weeks
prior to surgery
Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection
(Pneumonectomy, Lobectomy, or Formal Segmentectomy)
Percentage of thoracic surgical patients aged 18 years and older undergoing at least one
pulmonary function test within 12 months prior to a major lung resection (pneumonectomy,
lobectomy, or formal segmentectomy)
Hypertension (HTN): Plan of Care
Percentage of patient visits for patients aged 18 years and older with a diagnosis of HTN
during which either systolic blood pressure ≥ 140 mmHg OR diastolic blood pressure
≥ 90mm Hg, with documented plan of care for hypertension
Hypertension (HTN): Controlling High Blood Pressure
Percentage of patients aged 18 through 85 years of age who had a diagnosis of
hypertension (HTN) and whose BP was adequately controlled (< 140/90 mmHg)
Hypertension (HTN): Blood Pressure Measurement
Percentage of patient visits for patients aged 18 years and older with a diagnosis of HTN
with blood pressure (BP) recorded
Measure
Developer
Reporting
Options/Methods
b
Registry , GPRO
c
CMS/QIP
b
AMAPCPI/NCQA
Claims, Registry ,
Asthma Measures Group
(C/R)
b
AMAPCPI/NCQA
Claims, Registry ,
Asthma Measures Group
(C/R)
b
Registry
STS
b
Registry
STS
b
Claims, Registry
CMS/QIP
b
NCQA
c
EHR , GPRO ,
Cardiovascular Prevention
Measures Group (C/R)
EHR
b
AMA-PCPI
12/23/2011
Page 22 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
238.
239.
240.
241.
NQF
#
0022
0024
0038
0075
GPRO
IVD-1
242.
243.
244.
245.
N/A
0643
N/A
AQA
adopted
Version 6.2
Measure Title & Descriptiona
Drugs to be Avoided in the Elderly
Percentage of patients ages 65 years and older who received at least one drug to be
avoided in the elderly and/or two different drugs to be avoided in the elderly in the
measurement period
Weight Assessment and Counseling for Children and Adolescents
Percentage of children 2 through 18 years of age whose weight is classified based on BMI
percentile for age and gender
Childhood Immunization Status
The percentage of children two years of age who had four DTaP/DT, three IPV, one MMR,
three influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four
pneumococcal conjugate vaccines by their second birthday
Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein
(LDL-C) Control
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who
received at least one lipid profile within 12 months and whose most recent LDL-C level was
in control (less than 100 mg/dL)
Coronary Artery Disease (CAD): Symptom Management
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease
seen within a 12-month period and with results of an evaluation of level of activity AND an
assessment for the presence or absence of anginal symptoms, with a plan of care to
manage anginal symptoms, if present
Cardiac Rehabilitation Patient Referral from an Outpatient Setting
Percentage of patients evaluated in an outpatient setting who within the past 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
Hypertension: Blood Pressure Management
Percentage of patients aged 18 years and older with a diagnosis of hypertension seen
within a 12 month period with a blood pressure < 140/90 mmHg OR patients with a blood
pressure ≥ 140/90 mmHg and prescribed two or more anti-hypertensive medications during
the most recent office visit
Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with
Chronic Skin Ulcers
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of
chronic skin ulcer without the use of a wound surface culture technique
Measure
Developer
Reporting
Options/Methods
EHR
b
EHR
b
EHR
b
NCQA
NCQA
NCQA
b
NCQA
b
Claims, Registry , EHR ,
IVD Measures Group (C/R),
Cardiovascular Prevention
Measures Group (C/R),
c
GPRO
b
Registry
AMAPCPI/ACCF/
AHA
b
Registry
ACCF-AHA
b
Registry
AMAPCPI/ACCF/
AHA
b
Claims, Registry
AMAPCPI/NCQA
12/23/2011
Page 23 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
246.
NQF
#
AQA
adopted
247.
AQA
adopted
248.
AQA
adopted
249.
250.
251.
252.
253.
254.
Version 6.2
N/A
N/A
N/A
0503
0502
0651
Measure Title & Descriptiona
Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin
Ulcers
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of
chronic skin ulcer without a prescription or recommendation to use wet to dry dressings
Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic
Treatment Options for Alcohol Dependence
Percentage of patients aged 18 years and older with a diagnosis of current alcohol
dependence who were counseled regarding psychosocial AND pharmacologic treatment
options for alcohol dependence within the 12-month reporting period
Substance Use Disorders: Screening for Depression Among Patients with Substance
Abuse or Dependence
Percentage of patients aged 18 years and older with a diagnosis of current substance
abuse or dependence who were screened for depression within the 12-month reporting
period
Barrett's Esophagus
Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa
that also include a statement about dysplasia
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
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 ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor
2 Testing in breast cancer
Anticoagulation for Acute Pulmonary Embolus Patients
Anticoagulation ordered for patients who have been discharged from the emergency
department (ED) with a diagnosis of acute pulmonary embolus
Pregnancy Test for Female Abdominal Pain Patients
Percentage of female patients aged 14 to 50 who present to the emergency department
(ED) with a chief complaint of abdominal pain for whom a pregnancy test ordered
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
Developer
Reporting
Options/Methods
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
AMAPCPI/NCQA
b
Claims, Registry
CAP
b
Claims, Registry
CAP
b
Claims, Registry
CAP
b
Claims, Registry
ACEP
b
Claims, Registry
ACEP
b
Claims, Registry
ACEP
12/23/2011
Page 24 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
255.
256.
257.
258.
259.
260.
261.
262.
Version 6.2
NQF
#
0652
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Measure Title & Descriptiona
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)
Surveillance after Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
Percentage of patients 18 years of age or older undergoing endovascular abdominal aortic
aneurysm repair (EVAR) who have at least one follow-up imaging study after 3 months and
within 15 months of EVAR placement that documents aneurysm sac diameter and
endoleak status
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
Rate of Open Elective Repair of Small or Moderate 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 abdominal aortic
aneurysms who do not experience a major complication (discharge to home no later than
post-operative day #7)
Rate of Elective Endovascular Aortic Repair (EVAR) of Small or Moderate Abdominal
Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by PostOperative Day #2)
Percent of patients undergoing endovascular repair of small or moderate abdominal aortic
aneurysms (AAA) that do not experience a major complication (discharged to home no later
than post-operative day #2)
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major
Complications (Discharged to Home Post-Operative Day #2)
Percent of asymptomatic patients undergoing CEA who are discharged to home no later
than post-operative day #2
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
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
Developer
Reporting
Options/Methods
b
Claims, Registry
ACEP
b
Registry
SVS
b
Registry
SVS
b
Registry
SVS
b
Registry
SVS
b
Registry
SVS
b
Claims, Registry
AQC
b
Claims, Registry
ASBS
12/23/2011
Page 25 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
263.
264.
265.
266.
267.
268.
269.
270.
271.
Version 6.2
NQF
#
N/A
N/A
0645
N/A
N/A
N/A
N/A
N/A
N/A
Measure Title & Descriptiona
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 (excludes
open/incisional biopsies)
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
Biopsy Follow-Up
Percentage of patients whose biopsy results have been reviewed and communicated to the
primary care/referring physician and patient by the performing physician
Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies)
Percentage of patient visits with a diagnosis of epilepsy who had the type(s) of seizure(s)
and current seizure frequency(ies) for each seizure type documented in the medical record
Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome
All visits for patients with a diagnosis of epilepsy who had their etiology of epilepsy or with
epilepsy syndrome(s) reviewed and documented if known, or documented as unknown or
cryptogenic
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 about epilepsy and how its treatment may affect contraception and
pregnancy at least once a year
Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All
Documented
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease who have documented the disease type, anatomic location and activity, at least
once during the reporting period
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease who have been managed by corticosteroids greater than or equal to 10mg/day for
60 or greater consecutive days that have been prescribed corticosteroid sparing therapy in
the last reporting year
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related
Iatrogenic Injury – Bone Loss Assessment
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease who have received dose of corticosteroids greater than or equal to 10 mg/day for
60 or greater consecutive days and were assessed for risk of bone loss once per the
reporting year
Measure
Developer
Reporting
Options/Methods
b
Claims, Registry
ASBS
b
Registry
ASBS
b
Registry
AAD
b
Claims, Registry
AAN
b
Claims, Registry
AAN
b
Claims, Registry
AAN
IBD Measures Group (R)
AGA
IBD Measures Group (R)
AGA
IBD Measures Group (R)
AGA
12/23/2011
Page 26 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
272.
273.
274.
275.
276.
277.
NQF
#
N/A
N/A
N/A
N/A
N/A
N/A
278.
N/A
279.
N/A
280.
281.
Version 6.2
N/A
N/A
Measure Title & Descriptiona
Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease for whom influenza immunization was recommended, administered or previously
received during the reporting year
Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease that had pneumococcal vaccination administered or previously received
Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before
Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease for whom a tuberculosis (TB) screening was performed and results interpreted
within 6 months prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy
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 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
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 symptoms, including
presence or absence of snoring and daytime sleepiness
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
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
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
Dementia: Staging of Dementia
Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of
dementia was classified as mild, moderate or severe at least once within a 12 month period
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
Developer
Reporting
Options/Methods
IBD Measures Group (R)
AGA
IBD Measures Group (R)
AGA
IBD Measures Group (R)
AGA
IBD Measures Group (R)
AGA
AMAPCPI/NCQA
AMAPCPI/NCQA
AMAPCPI/NCQA
AMAPCPI/NCQA
AMA-PCPI
AMA-PCPI
Sleep Apnea Measures Group
(R)
Sleep Apnea Measures Group
(R)
Sleep Apnea Measures Group
(R)
Sleep Apnea Measures Group
(R)
Dementia Measures Group
(R)
Dementia Measures Group
(R)
12/23/2011
Page 27 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
282.
283.
284.
285.
286.
287.
288.
289.
290.
Version 6.2
NQF
#
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Measure Title & Descriptiona
Dementia: Functional Status Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an
assessment of patient’s functional status is performed and the results reviewed at least
once within a 12 month period
Dementia: Neuropsychiatric Symptom Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an
assessment of patient’s neuropsychiatric symptoms is performed and results reviewed at
least once in a 12 month period
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
Dementia: Screening for Depressive Symptoms
Percentage of patients, regardless of age, with a diagnosis of dementia who were screened
for depressive symptoms within a 12 month period
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
Dementia: Counseling Regarding Risks of Driving
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s)
who were counseled regarding the risks of driving and driving alternatives within a 12
month period
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 sources for support within a 12 month period
Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review
All patients with a diagnosis of Parkinson’s disease who had an annual assessment
including a review of current medications (e.g., medications than can produce Parkinsonlike signs or symptoms) and a review for the presence of atypical features (e.g., falls at
presentation and early in the disease course, poor response to levodopa, symmetry at
onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or
dysautonomia) at least annually
Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment
All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric
disorders or disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse
control disorder) at least annually
Measure
Developer
AMA-PCPI
AMA-PCPI
AMA-PCPI
AMA-PCPI
AMA-PCPI
AMA-PCPI
AMA-PCPI
Reporting
Options/Methods
Dementia Measures Group
(R)
Dementia Measures Group
(R)
Dementia Measures Group
(R)
Dementia Measures Group
(R)
Dementia Measures Group
(R)
Dementia Measures Group
(R)
Dementia Measures Group
(R)
Parkinson’s Disease
Measures Group (R)
AAN
AAN
Parkinson’s Disease
Measures Group (R)
12/23/2011
Page 28 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
291.
292.
293.
294.
295.
296.
297.
298.
299.
300.
301.
Version 6.2
NQF
#
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Measure Title & Descriptiona
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 at least annually
Parkinson’s Disease: Querying about Sleep Disturbances
All patients with a diagnosis of Parkinson’s disease (or caregivers, as appropriate) who
were queried about sleep disturbances at least annually.
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 at least annually
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 once annually
Hypertension: Appropriate Use of Aspirin or Other Antiplatelet or Anticoagulant
Therapy
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
were prescribed aspirin or other anticoagulant/antiplatelet therapy
Hypertension: Complete Lipid Profile
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
received a complete lipid profile within 24 months
Hypertension: Urine Protein Test
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
either have chronic kidney disease diagnosis documented or had a urine protein test done
within 36 months
Hypertension: Annual Serum Creatinine Test
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
had a serum creatinine test done within 12 months
Hypertension: Diabetes Mellitus Screening Test
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
had a diabetes screening test within 36 months
Hypertension: Blood Pressure Control
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
had most recent blood pressure level under control (at goal)
Hypertension: Low Density Lipoprotein (LDL-C) Control
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
had most recent LDL cholesterol level under control (at goal)
Measure
Developer
Reporting
Options/Methods
AAN
Parkinson’s Disease
Measures Group (R)
AAN
Parkinson’s Disease
Measures Group (R)
AAN
Parkinson’s Disease
Measures Group (R)
Parkinson’s Disease
Measures Group (R)
AAN
ABIM
ABIM
ABIM
Hypertension Measures
Group (R)
Hypertension Measures
Group (R)
Hypertension Measures
Group (R)
ABIM
Hypertension Measures
Group (R)
ABIM
Hypertension Measures
Group (R)
ABIM
Hypertension Measures
Group (R)
ABIM
Hypertension Measures
Group (R)
12/23/2011
Page 29 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
302.
303.
304.
305.
306.
307.
308.
309.
310.
Version 6.2
NQF
#
N/A
N/A
N/A
0004
0012
0014
0027
0032
0033
Measure Title & Descriptiona
Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed
Percentage of patients aged 15 through 90 years old with a diagnosis of hypertension who
received dietary and physical activity counseling at least once within 12 months
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following
Cataract Surgery
Percentage of patients aged 18 years and older in sample 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
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older in sample 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
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a)
Initiation, (b) Engagement
Percentage of adolescent and adult patients with a new episode of alcohol or other drug
(AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient
visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis
and who initiated treatment AND who had two or more additional services with an AOD
diagnosis within 30 days of the initial visit
Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)
Percentage of patients, regardless of age, who gave birth during a 12-month period who
were screened for HIV infection during the first or second prenatal visit
Prenatal Care: Anti-D Immune Globulin
Percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth
during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation
Smoking and Tobacco Use Cessation, Medical Assistance: a. Advising Smokers and
Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation
Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies
Percentage of patients aged 18 years and older who were current smokers or tobacco
users, who were seen by a practitioner during the measurement year and who received
advice to quit smoking or tobacco use or whose practitioner recommended or discussed
smoking or tobacco use cessation medications, methods or strategies
Cervical Cancer Screening
Percentage of women aged 21 through 63 years who received one or more Pap tests to
screen for cervical cancer
Chlamydia Screening for Women
Percentage of women aged 15 through 24 years who were identified as sexually active and
who had at least one test for chlamydia during the measurement year
Measure
Developer
ABIM
Reporting
Options/Methods
Hypertension Measures
Group (R)
b
Registry , Cataract Measures
Group (R)
AAO
b
Registry , Cataract Measures
Group (R)
AAO
EHR
b
EHR
b
EHR
b
EHR
b
EHR
b
EHR
b
NCQA
AMA-PCPI
AMA-PCPI
NCQA
NCQA
NCQA
12/23/2011
Page 30 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#
311.
312.
313.
NQF
#
0036
0052
0575
GPRO
DM-10
314.
GPRO
DM-11
315.
GPRO
DM-12
316.
317.
0729
Compo
-site
only
0729
Compo
-site
only
N/A
N/A
Measure Title & Descriptiona
Use of Appropriate Medications for Asthma
Percentage of patients aged 5 through 50 years of age who were identified as having
persistent asthma and were appropriately prescribed medication during the measurement
year
Low Back Pain: Use of Imaging Studies
Percentage of patients with a primary diagnosis of low back pain who did not have an
imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis
Diabetes Mellitus: Hemoglobin A1c Control (<8%)
The percentage of patients 18 through 75 years of age with a diagnosis of diabetes (type 1
or type 2) who had HbA1c < 8%
Diabetes Mellitus: Daily Aspirin Use for Patients with Diabetes and Ischemic Vascular
Disease
Percentage of patients aged 18 to 75 years of age with diabetes mellitus and ischemic
vascular disease with documented daily aspirin use during the measurement year unless
contraindicated
Diabetes Mellitus: Tobacco Non Use
Percentage of patients with a diagnosis of diabetes who indicated they were tobacco nonusers
Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL)
Test Performed AND Risk-Stratified Fasting LDL
Percentage of patients aged 20 through 79 years whose risk factors* have been assessed
and a fasting LDL test has been performed AND who had a fasting LDL test performed and
whose risk-stratified* fasting LDL is at or below the recommended LDL goal
Preventive Care and Screening: Screening for High Blood Pressure
Percentage of patients aged 18 and older who are screened for high blood pressure
GPRO
Prev-11
318.
GPRO
Care-2
0101
Falls: Screening for Future Fall Risk
Percentage of patients aged 65 years and older who were screened for future fall risk at
least once within 12 months
Measure
Developer
Reporting
Options/Methods
EHR
b
EHR
b
NCQA
NCQA
b
EHR , GPRO
c
NCQA
GPRO
c
GPRO
c
MNCM
MNCM
EHR
b
CMS/QIP
b
CMS/QIP
Claims, Registry ,
Cardiovascular Prevention
b
Measures Group (C/R), EHR ,
c
GPRO
c
GPRO
AMAPCPI/NCQA
Physician Quality Reporting measures, including patient-level measure(s), may be reported for the same patient by multiple eligible professionals practicing
under the same Tax Identification Number (TIN). If a patient sees multiple providers during the reporting period, that patient can be counted for each individual
NPI reporting if the patient encounter(s) meet denominator inclusion. The following is an example of two provider NPIs (National Provider Identifiers), billing
under the same TIN who are intending to report Physician Quality Reporting Measure #6: Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed
for Patients with CAD. Provider A sees a patient on February 2, 2012 and prescribes an aspirin and reports the appropriate quality-data code (QDC) for measure
Version 6.2
12/23/2011
Page 31 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
#6. Provider B sees the same patient at an encounter on July 16, 2012 and verifies that the patient has been prescribed and is currently taking an aspirin.
Provider B must also report the appropriate QDCs for the patient at the July encounter to receive credit for reporting measure #6.
a
Measure titles and descriptions for some measures may vary by measure reporting options/methods for a particular program year. This is due to the timing of
measure specification preparation for the various reporting options/methods. The titles and descriptions referenced in this document refer to the claims/registry
measure specifications. Please refer to the measure specifications that apply to the other reporting options/methods for the measure details (e.g. measure titles
and descriptions) that apply to those specific options/methods. Titles and descriptions for some measures may vary between measure reporting options/methods.
This is due to the timing of measure preparation for the different reporting options/methods.
b
A list of qualified Registries and EHR Vendors for the 2012 program will be available on the Alternative Reporting Mechanisms section available from the
navigation bar on the left side of the CMS Physician Quality Reporting website at http://www.cms.gov/pqrs. Please visit this site periodically for updates and
contact your EHR vendor or registry to determine if they are planning to become qualified for upcoming program years.
c
The Group Practice Reporting Option (GPRO) is only available to those group practices who have been selected. For information on how to become a selected
group practice, refer to the downloads on the Group Practice Reporting Option section available from the navigation bar on the left side of the CMS Physician
Quality Reporting System website at http://www.cms.gov/pqrs. Please visit this site periodically for updates.
Appendix I - Measure Specifications
Reporting
Option/Method
Claims
Measure Specification Name
CMS Physician Quality Reporting website location
2012 Physician Quality Reporting Measure
Specifications Manual for Claims and Registry
Reporting of Individual Measures
http://www.cms.gov/pqrs > Measures Codes page >
2012 Physician Quality Reporting Measure Specifications Manual for Claims
and Registry Reporting of Individual Measures and Release Notes ZIP file
Registry
2012 Physician Quality Reporting Measure
Specifications Manual for Claims and Registry
Reporting of Individual Measures
http://www.cms.gov/pqrs > Measures Codes page >
2012 Physician Quality Reporting Measure Specifications Manual for Claims
and Registry Reporting of Individual Measures and Release Notes ZIP file
EHR
2012 EHR Measure Specifications
http://www.cms.gov/pqrs > Alternative Reporting Mechanisms page >
EHR Documents for Eligible Professionals ZIP file
2012 Physician Quality Reporting Measures
Groups Specifications Manual and Release
Notes
http://www.cms.gov/pqrs > Measures Codes page >
2012 Physician Quality Reporting Measures Groups Specifications Manual and
Release Notes ZIP file
Electronic Health
Record
Measures
Groups
NOTE: Refer to these measure specifications for more
information on which reporting mechanism (claims or
registry) may be used to submit each Measures
Group.
Version 6.2
12/23/2011
Page 32 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
Appendix I - Measure Specifications
Reporting
Option/Method
GPRO
Group Practice
Reporting Option
Version 6.2
Measure Specification Name
CMS Physician Quality Reporting website location
2012 Physician Quality Reporting GPRO
Narrative Measure Specifications and Release
Notes
http://www.cms.gov/pqrs > Group Practice Reporting Option page >
2012 Physician Quality Reporting GPRO Narrative Measure Specifications and
Release Notes ZIP file
12/23/2011
Page 33 of 34
2012 Physician Quality Reporting System (Physician Quality Reporting) Measures List
Appendix II - Measure Developer/Contact Information
Acronym
AAD
Full Name
American Academy of Dermatology
AAN
AAO
ABIM
ACC
ACEP
AGA
AHA
AMA-PCPI
APMA
American Academy of Neurology
American Academy of Ophthalmology
American Board of Internal Medicine
American College of Cardiology
American College of Emergency Physicians
American Gastroenterological Association
American Heart Association
American Medical Association-sponsored Physician
Consortium on Performance Improvement
American Podiatric Medical Association
ASBS
ASH
ASCO
ASHA
ASA
AQC
CAP
CMS
MNCM
QIP
FOTO
NCCN
NCQA
STS
SVS
American Society of Breast Surgeons
American Society of Hematology
American Society of Clinical Oncology
American Speech-Language-Hearing Association
American Stroke Association
Audiology Quality Consortium
College of American Pathologists
Centers for Medicare & Medicaid Services
Minnesota Community Measurement
Quality Insights of Pennsylvania
Focus on Therapeutic Outcomes
National Comprehensive Cancer Network
National Committee for Quality Assurance
The Society of Thoracic Surgeons
Society of Vascular Surgeons
Contact
e-mail questions and comments to http://www.aad.org/education-and-qualitycare/performance-measurement-and-quality-reporting
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected] or [email protected]
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected]
e-mail questions and comments to the PCPI at [email protected]
e-mail questions and comments at
http://www.apma.org/s_apma/secmember.asp?CID=421&DID=17174
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected]
http://www.asco.org and click on “Contact Us”
e-mail questions and comments to [email protected]
http://www.heart.org/HEARTORG/General/Contact-Us_UCM_308813_Article.jsp
http://www.asha.org/advocacy/audiologypqri
e-mail questions and comments to http://www.cap.org
e-mail questions and comments to [email protected]
e-mail questions and comments to [email protected]
e-mail questions and comments to http://usqualitymeasures.org/qm/contact.aspx
e-mail questions and comments to [email protected]
http://www.nccn.org/about/contact.asp
http://www.ncqa.org and click on “Contact Us”
e-mail questions and comments to [email protected]
e-mail questions and comments at http://www.vascularweb.org
The symbols provided in this list denote the measure developer/contact responsible for the 2012 Physician Quality Reporting quality measure. Copyright detail for
each measure developer is included in the 2012 Physician Quality Reporting Measure Specifications Manual for Claims and Registry.
Version 6.2
12/23/2011
Page 34 of 34
| File Type | application/pdf |
| File Title | 2012 Physician Quality Reporting Measures List |
| Subject | Physician Quality Reporting System, physician, quality, reporting, system, measure, measures, owners, contact |
| Author | PMBR/CMS |
| File Modified | 2011-12-23 |
| File Created | 2011-12-23 |