Registry-based and Qualified Clinical Data Registry-based Reporting Mechanisms (Eligible Professionals Participating Individually or as Part of a Group Practice)

2015 Physician Quality Reporting System (PQRS)
Measure-Applicability Validation (MAV) Process for
Registry-Based Reporting of Individual Measures
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2015 PQRS MEASURE-APPLICABILITY VALIDATION (MAV)
PROCESS FOR REGISTRY-BASED MEASURES
The 2015 Physician Quality Reporting System (PQRS) requires eligible professionals to report at least nine measures across
three domains within the period January 1, 2015 – December 31, 2015. The Centers for Medicare & Medicaid Services (CMS)
recognizes that a limited number of eligible professionals may not be able to identify nine measures across three domains that
are applicable to their practice. The purpose of this guidance document is to carefully delineate the Measure-Applicability
Validation (MAV) processes and requirements as it pertains to PQRS reporting via registry. See the MAV Glossary for additional
terms and review Appendices A, B, and C for measure specific-information.
The objective of registry-based MAV is for CMS to validate if there were additional measure(s) or domain(s) that may have been
applicable to submit by the eligible professional or group practice. For registry-based submissions, MAV applies a one-step
validation process of the clinical/domain relation test. Eligible professionals or group practices that submit less than nine
measures or less than three NQS domains would be subject to MAV. If the eligible professional or group practice passes MAV,
they would avoid the 2017 PQRS payment adjustment. For those eligible professionals or group practices that fail MAV, the
2017 PQRS Payment Adjustment would apply.
Case Study 1: Ophthalmologist - When and How MAV Applies for Registry Submission

If an ophthalmologist satisfactorily reports measures #130 and #226 and does not submit any other measures, then CMS will
analyze the submitted data to complete the clinical/relation domain test. MAV is only applied if the ophthalmologist satisfactorily
reports on one to eight measures or nine or more measures with less than three domains. If the ophthalmologist submits at least
nine measures across three domains, then MAV does not apply.
Note: If the ophthalmologist does not submit at least one cross-cutting measure (when applicable) then that individual
provider with face-to-face encounters will be automatically subject to the 2017 PQRS payment adjustment and MAV will
not be utilized.
Step 1, when registry-based MAV applies, CMS analyzes the submitted data to evaluate if there are any other measures or
domains that could have been applicable based on the clinical clusters as referenced in Table 1. PQRS measure #12 and #141 are
found in Cluster 15: Primary Open-Angle Glaucoma. CMS would then review the cluster to evaluate if there were any other
applicable measures within that cluster that could have been submitted.
For example, Dr. Smith, an ophthalmologist, feels that the only applicable measures for him to submit are measures #12 and
#141. He reports these measures based on the CPT code 92012. This CPT code is found in the denominator criteria of both
measures #12 and #141. Since he has satisfactorily reported on Measures #12 and #41, he is subject to the MAV analysis. CMS
then evaluates which clinical clusters may be applicable to Dr. Smith based on the clusters as they are represented in the registrybased MAV document. If CMS determines that Dr. Smith may have been able to submit the measures in Cluster 15: Primary
Open-Angle Glaucoma, CMS then reviews the cluster to determine if Dr. Smith could have submitted additional measures. Since
Dr. Smith satisfactorily reported both measures within this cluster, he would “pass” MAV. If Dr. Smith only submitted measure #12,
CMS would have determined that he/she could have also submitted measure #141 as the patient populations within these
measures are very similar. Dr. Smith would have then “failed” MAV.

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Figure 1: Eligibilty for MAV

MAV will apply If...
•Satisfactorily
Reporting 1 - 8
measures.
•Satisfactorily
Reporting less than
3 domains.

MAV Only Applied After the Following are Met:
 Eligible professionals or group practices who satisfactorily submit quality data codes (QDCs) for less than nine
measures or less than three domains.
Note: MAV is a process to review and validate an individual eligible professional’s or group practice’s inability
to submit on nine measures across three domains. CMS will analyze data to validate, using the clinical
relation/domain test to confirm that more measures and/or NQS domains were not applicable to the eligible
professional’s or group practice’s scope of practice. If additional measures or domains are found to be
applicable through MAV, the eligible professional would be subject to the 2017 PQRS payment adjustment.
 Eligible professionals and group practices must satisfactorily report on at least 50 percent of their eligible patients or
encounters for each measure.
 At least one cross-cutting measure must be satisfactorily reported for those individual providers or group practices
with face-to-face encounters. CMS will analyze claims data to determine if at least 15 cross-cutting measure
denominator eligible encounters can be associated with the eligible professional. If it is determined that at least
one cross-cutting measure was not reported, the individual eligible professional or group practice with face-to-face
encounters will be automatically subject to the 2017 PQRS payment adjustment and MAV will not be utilized for that
individual provider. For those individual eligible professionals or group practices with no face-to-face encounters, MAV
will be utilized for those that submit less than nine measures and/or less than three NQS domains.
 For measures submitted, there must be at least one patient or procedure in the numerator of the rate for the measure
to be counted as meeting performance. For measures that move towards 100% to indicate higher quality outcome, the
rate must be greater than 0%. For inverse measures where higher quality moves the rate towards 0% the rate must be
less than 100%. Eligible professionals or group practices who fail these criteria for a submitted measure will not
proceed through MAV and will be subject to the 2017 payment adjustment.
Figure 2: 2017 PQRS Payment Adjustment Will Apply

Reporting less than 50%
of Medicare
Part B FFS patients

Individual provider with
face-to-face encounters
who does not
satisfactorily report at
least one
cross-cutting measure

OR

OR

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No patient or procedure
that qualifies for the
numerator of the
performance measure
(i.e. rate = 0%, or 100%
for inverse measures)

If any one of these
conditions exist, then
MAV will not be used
and the 2017 PQRS
Payment Adjustment
will apply.

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Please refer to the 2015 Physician Quality Reporting System (PQRS) Measure-Applicability Validation (MAV) Process Flow for
Registry-Based Reporting of Individual Measures for Payment Adjustment for further guidance.
The Measure-Applicability Validation process, shown in Figure 3 has only one step for registry-based MAV.
Figure 3: Step 1, Clinical Relation/Domain Test, for Registry-Based MAV

Step 1: Clinical Relation/Domain Test
The clinical relation/domain test is the first and only-step in the registry-based MAV process that will be applied to those who are
subject to the validation process of satisfactorily reported measures OR NQS domains (i.e. those eligible professionals or group
practices that submitted less than nine measures or measures from less than three domains). (Please note that the minimum
threshold test used in claims-based MAV is not analyzed for registry-based MAV.)
The clinical relation/domain test is based on two factors:
1. How the measure(s) satisfactorily reported currently apply within the eligible professionals and group practices, and
2. The concept that if one measure in a cluster of measures related to a particular clinical topic or eligible professional
service is applicable to an eligible professional’s practice, then other clinically related measures within the clinical
cluster may also be applicable. Clinical clusters within MAV are measures that are clinically related based by patient
type, procedure, or possible clinical action.
For those eligible professionals who satisfactorily submit QDCs for nine PQRS measures for less than three NQS domains,
there will be a determination if additional measures with additional NQS domains may also apply to the eligible professional or
group practice based on the clinical cluster. If no other measures or NQS domains are identified through this process the eligible
professional or group practice would avoid the 2017 PQRS payment adjustment. Case Study 2 shows how the clinical
relation/domain test will be applied for registry submissions:
Case Study 2: Pathologist - How the Registry-based MAV Clinical Relation/Domain Test Will Be Applied:

A pathologist, identified as an eligible professional who is subject to MAV due to meeting the pre-requisites for MAV, reported
QDCs for one of the PQRS measures related to pathology. CMS will determine if the submitted measure is contained within a
cluster or is excluded from a cluster. If the measure is contained within a cluster, then CMS will analyze registry data to evaluate if
any of the other measures or domains within the clinical cluster may have also been applicable. Upon further analysis, CMS
determined that some of the other measures in the cluster (submitted by the registry) would be applicable to the physician’s or
group practice and could have been submitted.

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Other Program Integrity Considerations
QDCs submitted via registry must be supported in medical record documentation. Other laws and regulations relating to
Medicare program integrity may also apply to PQRS.
CMS may determine that it is necessary to modify the MAV process after the start of the 2015 reporting period. However, any
changes will result in the MAV process being applied more leniently, thereby
1. Allowing a greater number of eligible professionals to pass validation, and
2. Causing no eligible professional or group practice that would otherwise have passed, to fail. Any modifications will be
published on the CMS PQRS website as soon as possible after determination that a change is needed.

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Figure 4: Registry-Based MAV Process Flow

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Registry-Based MAV Glossary of Terms
Cluster
Measures related to a particular clinical topic or individual eligible professional service that is applicable to a specific, individual
EP or group practice.
Domains
Represent the Department of Health and Human Services’ (HHS’s) NQS priorities for healthcare quality improvement. A domain
is automatically included in the structure of each measure. The six NQS domains mirror the six priorities of the NQS that are
developed for the pursuit of NQS’s three broad aims:
1. Better Care: Improve the overall quality by making health care more patient-centered, reliable, accessible, and safe.
2. Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven
interventions to address behavioral, social, and environmental determinants of health in addition to delivering
higher-quality care.
3. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
The six NQS Domains associated with the PQRS quality measures are as follows:
1. Patient Safety
2. Person and Caregiver-Centered Experience and Outcomes
3. Communication and Care Coordination
4. Effective Clinical Care
5. Community/Population Health
6. Efficiency and Cost Reduction
Eligible professional (EP)
Determine if you are eligible to participate for purposes of the PQRS incentive payment and payment adjustment. A list of
eligible medical care professionals considered eligible to participate in PQRS is available on the CMS.gov Web site at this path:
CMS.gov/PQRS> How To Get Started>Eligible Medical Care Professionals. Read this list carefully, as not all entities are
considered “eligible professionals” because they are reimbursed by Medicare under other fee schedule methods than the
Physician Fee Schedule (PFS).
Satisfactorily Reporting Criteria for Submission via Registry
Submit at least nine measures covering at least three of the National Quality Strategy domains, and submit each measure for at
least fifty percent (50%) of the eligible professional’s or group practice’s Medicare Part B FFS patients seen during the reporting
period to which the measure applies;
 If submitting less than nine measures across at least three National Quality Strategy (NQS) domains apply to the
eligible professional or group practice: Report one to eight measures covering one to three National Quality Strategy
domains and
o Submit one to eight measures covering one to three NQS domains and Measures with a zero percent (0%)
performance rate would not be counted.
o Submit each measure for at least 50% of the Medicare Part B Fee-for-Service (FFS) patients seen during the
reporting period to which the measure applies.
o Submit at least one cross-cutting measure if eligible professional bills for face-to-face encounters
 Measures with a zero percent (0%) performance rate would not be counted.


Refer to the Code of Federal Regulations statute §414.90 Physician Quality Reporting System (PQRS) for broader
application of the term satisfactorily reporting for PQRS via Registry submission.

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The list of clusters of related measures and the PQRS measures that are included within each cluster are presented
below.
Figure 5: Example of Cluster of Clinically Related Measures

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Table 1: PQRS Clusters of Clinically Related Measures Used in MAV Step 1: Clinical Relation/Domain Test
of the 2015 Registry-Based Submission of Individual Measures

Cluster
Number

Cluster Title

Measure
Number

1

Falls Care

154

Patient Safety

Falls: Risk Assessment

155

Communication and
Care Coordination

Falls: Plan of Care

2

Diabetic Care

1

Domain

Measure Title

Effective Clinical Care Diabetes: Hemoglobin A1c Poor Control

119

Effective Clinical Care Diabetes: Medical Attention for Nephropathy

130

Patient Safety

Documentation of Current Medications in the Medical
Record

Note: When submitting #130 alone, it is not subject to MAV
3

4

Diabetes Mellitus
Foot Care

Chronic
Obstructive
Pulmonary
Disease (COPD)
Care

126

Effective Clinical Care Diabetes Mellitus: Diabetic Foot and Ankle Care,
Peripheral Neuropathy - Neurological Evaluation

127

Effective Clinical Care Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer
Prevention – Evaluation of Footwear

51

Effective Clinical Care Chronic Obstructive Pulmonary Disease (COPD):
Spirometry Evaluation

52

Effective Clinical Care Chronic Obstructive Pulmonary Disease (COPD):
Inhaled Bronchodilator Therapy

110

Community/Population Preventive Care and Screening: Influenza
Health
Immunization

130
226

Patient Safety

Documentation of Current Medications in the Medical
Record

Community/Population Preventive Care and Screening: Tobacco Use:
Health
Screening and Cessation Intervention

Note: When submitting #110, #130 or #226, they are not subject to MAV for this clinical
cluster. It is expected to submit these measures if #51 and/or #52 are submitted.
5

Asthma Care

53
110

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Effective Clinical Care Asthma: Pharmacologic Therapy for Persistent
Asthma – Ambulatory Care Setting
Community/
Preventive Care and Screening: Influenza
Population Health
Immunization

130

Patient Safety

Documentation of Current Medications in the Medical
Record

226

Community/
Population Health

Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
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Cluster
Number

Cluster Title

5

Asthma Care

Measure
Number
398

Domain

Measure Title

Person and Caregiver- Optimal Asthma Care- Control Component
Centered Experience
and Outcomes
Note: When submitting #110, #130 or #226, they are not subject to MAV for
this clinical cluster. It is expected to submit these measures if #53 and/or #398
are submitted.

6

7

8

9

10

Hematology Care

Melanoma Care

Oncology Pain
Care

Prostate Cancer
Care

Osteoporosis
Care

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67

Effective Clinical Care Hematology: Myelodysplastic Syndrome (MDS) and
Acute Leukemias: Baseline Cytogenetic Testing
Performed on Bone Marrow

68

Effective Clinical Care Hematology: Myelodysplastic Syndrome (MDS):
Documentation of Iron Stores in Patients Receiving
Erythropoietin Therapy

69

Effective Clinical Care Hematology: Multiple Myeloma: Treatment with
Bisphosphonates

70

Effective Clinical Care Hematology: Chronic Lymphocytic Leukemia (CLL):
Baseline Flow Cytometry

137

Communication and
Care Coordination

Melanoma: Continuity of Care-Recall System

138

Communication and
Care Coordination

Melanoma: Coordination of Care

224

Efficiency and Cost
Reduction

Melanoma: Overutilization of Imaging Studies in
Melanoma

143

Person and Caregiver- Oncology: Medical and Radiation – Pain Intensity
Centered Experience Quantified
and Outcomes

144

Person and Caregiver- Oncology: Medical and Radiation – Plan of Care for
Centered Experience Pain
and Outcomes

102

Efficiency and Cost
Reduction

104

Effective Clinical Care Prostate Cancer: Adjuvant Hormonal Therapy for High
Risk Prostate Cancer Patients

24

Communication and
Care Coordination

Prostate Cancer: Avoidance of Overuse of Bone Scan
for Staging Low Risk Prostate Cancer Patients

Osteoporosis: Communication with the Physician
Managing On-Going Care Post-Fracture of Hip, Spine,
or Distal Radius for Men and Women Aged 50 Years
and Older

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Cluster
Number
10

Cluster Title
Osteoporosis
Care

Measure
Number
40
110
130
226

Domain

Measure Title

Effective Clinical Care Osteoporosis: Management Following Fracture of Hip,
Spine, or Distal Radius for Men and Women Aged 50
Years and Older
Community/
Preventive Care and Screening: Influenza
Population Health
Immunization
Patient Safety

Documentation of Current Medications in the Medical
Record

Community/
Population Health

Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention

Note: When submitting #110, #130 or #226, they are not subject to MAV for this clinical
cluster. It is expected to submit these measures if #24 and/or #40 are submitted.
11

Appropriate
Test/Treatment
for Children

12

13

Acute Otitis
Externa

Adult Sinusitis
Care

65

Efficiency and Cost
Reduction

Appropriate Treatment for Children with Upper
Respiratory Infection (URI)

66

Efficiency and Cost
Reduction

Appropriate Testing for Children with Pharyngitis

91

Effective Clinical Care Acute Otitis Externa (AOE): Topical Therapy

93

Efficiency and Cost
Reduction

Acute Otitis Externa (AOE): Systemic Antimicrobial
Therapy – Avoidance of Inappropriate Use

331

Efficiency and Cost
Reduction

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis
(Appropriate Use)

Efficiency and Cost
Reduction

Adult Sinusitis: Appropriate Choice of Antibiotic:
Amoxicillin Prescribed for Patients with Acute Bacterial
Sinusitis (Appropriate Use)

Efficiency and Cost
Reduction

Adult Sinusitis: Computerized Tomography (CT) for
Acute Sinusitis (Overuse)

Efficiency and Cost
Reduction

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

332
333
334
14

15

Pathology Breast
Cancer

Primary OpenAngle Glaucoma

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99

Effective Clinical Care Breast Cancer Resection Pathology Submitting: pT
Category (Primary Tumor) and pN Category (Regional
Lymph Nodes) with Histologic Grade

251

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

12

Effective Clinical Care Primary Open-Angle Glaucoma (POAG): Optic Nerve
Evaluation

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Cluster
Number

Cluster Title

15

Primary OpenAngle Glaucoma

16

Age-Related
Macular
Degeneration

17

Cataract Care

Measure
Number
141

Domain
Communication and
Care Coordination

Effective Clinical Care Age-Related Macular Degeneration (AMD): Dilated
Macular Examination

140

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

191

Effective Clinical Care Cataracts: 20/40 or Better Visual Acuity within 90 Days
Following Cataract Surgery
Patient Safety

Person and Caregiver- Cataracts: Improvement in Patient’s Visual Function
Centered Experience within 90 Days Following Cataract Surgery
and Outcomes

304

Person and Caregiver- Cataracts: Patient Satisfaction within 90 Days
Centered Experience following Cataract Surgery
and Outcomes
Patient Safety

Cataract Surgery with Intra-Operative Complications
(Unplanned Rupture of Posterior Capsule requiring
unplanned vitrectomy)

389

Effective Clinical Care Cataract Surgery: Difference Between Planned and
Final Refraction

81

Communication and
Care Coordination

82
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Cataracts: Complications within 30 Days Following
Cataract Surgery Requiring Additional Surgical
Procedures

303

388

Adult Renal
Disease Care

Primary Open-Angle Glaucoma (POAG): Reduction of
Intraocular Pressure (IOP) by 15% OR Documentation
of a Plan of Care

14

192

18

Measure Title

Adult Kidney Disease: Hemodialysis Adequacy: Solute

Effective Clinical Care Adult Kidney Disease: Peritoneal Dialysis Adequacy:
Solute
Community/
Preventive Care and Screening: Influenza
Population Health
Immunization

121

Effective Clinical Care Adult Kidney Disease: Laboratory Testing (Lipid
Profile)

122

Effective Clinical Care Adult Kidney Disease: Blood Pressure Management

130

Patient Safety

Documentation of Current Medications in the Medical
Record

226

Community/
Population Health

Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention

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Cluster
Number

Cluster Title

18

Adult Renal
Disease Care

19

Adult Renal
Catheter Care

20

21

22

Pediatric Kidney
Disease Care

Stroke
Management

Perioperative
Care

Measure
Number

329

Effective Clinical Care Adult Kidney Disease: Catheter Use at Initiation of
Hemodialysis

330

Effective Clinical Care Adult Kidney Disease: Catheter Use for Greater Than
or Equal to 90 Days

327

Effective Clinical Care Pediatric Kidney Disease: Adequacy of Volume
Management

328

Effective Clinical Care Pediatric Kidney Disease: ESRD Patients Receiving
Dialysis: Hemoglobin Level < 10g/dL

32

Effective Clinical Care Stroke and Stroke Rehabilitation: Discharged on
Antithrombotic Therapy

33

Effective Clinical Care Stroke and Stroke Rehabilitation: Anticoagulant
Therapy Prescribed for Atrial Fibrillation (AF) at
Discharge

187

Effective Clinical Care Stroke and Stroke Rehabilitation: Thrombolytic
Therapy

21

23
Coronary Artery
Bypass Graft
Care

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Measure Title

Note: When submitting #110, #130 or #226, they are not subject to MAV for this clinical
cluster. It is expected to submit these measures if #81, #82, #121and/or #122 are
submitted.

22

23

Domain

Patient Safety

Perioperative Care: Selection of Prophylactic Antibiotic
– First OR Second Generation Cephalosporin

Patient Safety

Perioperative Care: Discontinuation of Prophylactic
Parenteral Antibiotics (Non-Cardiac Procedures)

Patient Safety

Perioperative Care: Venous Thromboembolism (VTE)
Prophylaxis (When Indicated in ALL Patients)

43

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

164

Effective Clinical Care Coronary Artery Bypass Graft (CABG): Prolonged
Intubation

165

Effective Clinical Care Coronary Artery Bypass Graft (CABG): Deep Sternal
Wound Infection Rate

166

Effective Clinical Care Coronary Artery Bypass Graft (CABG): Stroke

167

Effective Clinical Care Coronary Artery Bypass Graft (CABG): Postoperative
Renal Failure

168

Effective Clinical Care Coronary Artery Bypass Graft (CABG): Surgical ReExploration

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Cluster
Number

Cluster Title

Measure
Number

Domain

24

Anesthesia Care

76

Patient Safety

Prevention of Central Venous Catheter (CVC) - Related
Bloodstream Infections

193

Patient Safety

Perioperative Temperature Management

Measure Title

Note: When submitting #76 alone, it is not subject to MAV
25

26

27

Endoscopy and
Polyp
Surveillance

Urinary
Incontinence
Care

Coronary Disease
Care

185

Communication and
Care Coordination

Colonoscopy Interval for Patients with a History of
Adenomatous Polyps – Avoidance of Inappropriate
Use

320

Communication and
Care Coordination

Appropriate Follow-Up Interval for Normal
Colonoscopy in Average Risk Patients

48

Effective Clinical Care Urinary Incontinence: Assessment of Presence or
Absence of Urinary Incontinence in Women Aged 65
Years and Older

50

Person and Caregiver- Urinary Incontinence: Plan of Care for Urinary
Centered Experience Incontinence in Women Aged 65 Years and Older
and Outcomes

6

Effective Clinical Care Coronary Artery Disease (CAD): Antiplatelet Therapy

7
110

Effective Clinical Care Coronary Artery Disease (CAD): Beta-Blocker Therapy
- Prior Myocardial Infarction (MI) or Left Ventricular
Systolic Dysfunction (LVEF < 40%)
Community/
Preventive Care and Screening: Influenza
Population Health
Immunization

118

Effective Clinical Care Coronary Artery Disease (CAD): AngiotensinConverting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy - Diabetes or Left
Ventricular Systolic Dysfunction (LVEF < 40%)

130

Patient Safety

Documentation of Current Medications in the Medical
Record

226

Community/
Population Health

Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention

242

Effective Clinical Care Coronary Artery Disease (CAD): Symptom
Management

Note: When submitting #110, #130 or #226, they are not subject to MAV for this clinical
cluster. It is expected to submit these measures if #6, #7, #118 and/or #242 are submitted.

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Cluster
Number

Cluster Title

28

Heart Failure
Care

Measure
Number
5

8
110

Domain

Measure Title

Effective Clinical Care Heart Failure (HF): Angiotensin-Converting Enzyme
(ACE) Inhibitor or Angiotensin Receptor Blocker (ARB)
Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
Effective Clinical Care Heart Failure (HF): Beta-Blocker Therapy for Left
Ventricular Systolic Dysfunction (LVSD)
Community/
Preventive Care and Screening: Influenza
Population Health
Immunization

130

Patient Safety

Documentation of Current Medications in the Medical
Record

226

Community/
Population Health

Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention

Note: When submitting #110, #130 or #226, they are not subject to MAV for this clinical
cluster. It is expected to submit these measures if #5 and/or #8 are submitted.
29

Cardiac Stress
Imaging

322
323
324

32

Carotid Artery
Stenting Care

344
345

33

Carotid
Endarterectomy
Care

260
346

34

Endovascular
Aneurysm Repair

258

259

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Efficiency and Cost
Reduction

Cardiac Stress Imaging Not Meeting Appropriate Use
Criteria: Preoperative Evaluation in Low Risk Surgery
Patients
Efficiency and Cost Cardiac Stress Imaging Not Meeting Appropriate Use
Reduction
Criteria: Routine Testing After Percutaneous Coronary
Intervention (PCI)
Efficiency and Cost Cardiac Stress Imaging Not Meeting Appropriate Use
Reduction
Criteria: Testing in Asymptomatic, Low Risk Patients
Effective Clinical Care Rate of Carotid Artery Stenting (CAS) for
Asymptomatic Patients, Without Major Complications
(Discharged to Home by Post-Operative Day #2)
Effective Clinical Care Rate of Postoperative Stroke or Death in
Asymptomatic Patients Undergoing Carotid Artery
Stenting (CAS)
Patient Safety
Rate of Carotid Endarterectomy (CEA) for
Asymptomatic Patients, without Major Complications
(Discharged to Home Post-Operative #2)
Effective Clinical Care Rate of Postoperative Stroke or Death in
Asymptomatic Patients Undergoing Carotid
Endarterectomy (CEA)
Patient Safety
Rate of Open Repair of Small or Moderate NonRuptured Abdominal Aortic Aneurysms (AAA) without
Major Complications (Discharged to Home by PostOperative Day #7)
Patient Safety
Rate of Endovascular Aneurysm Repair (EVAR) of
Small or Moderate Non-Ruptured Abdominal Aortic
Aneurysms (AAA) without Major Complications
(Discharged to Home Post-Operative Day #2)
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Cluster
Number

Cluster Title

34

Endovascular
Aneurysm Repair

35

Breast Surgery
Care

Measure
Number
347
262
263
264

36

Functional Care

217
218
219
220
221
222

223
37

Retinal Care

384
385

38

Heart Rhythm
Care

348
392
393

39

Pathology Lung
Cancer

395
396

Domain

Measure Title

Patient Safety

Rate of Endovascular Aneurysm Repair (EVAR) of
Small or Moderate Non-Ruptured Abdominal Aortic
Aneurysms (AAA) Who Die While in Hospital
Patient Safety
Image Confirmation of Successful Excision of ImageLocalized Breast Lesion
Effective Clinical Care Preoperative Diagnosis of Breast Cancer
Effective Clinical Care Sentinel Lymph Node Biopsy for Invasive Breast
Cancer
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Knee Impairments
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Hip Impairments
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Lower Leg, Foot or Ankle
Impairments
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Lumbar Spine Impairments
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Shoulder Impairments
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Elbow, Wrist or Hand
Impairments
Communication and Functional Deficit: Change in Risk-Adjusted Functional
Care Coordination
Status for Patients with Neck, Cranium, Mandible,
Thoracic Spine, Ribs, or Other General Orthopedic
Impairments
Effective Clinical Care Adult Primary Rhegmatogenous Retinal Detachment
Repair Success Rate
Effective Clinical Care Adult Primary Rhegmatogenous Retinal Detachment
Surgery Success Rate
Patient Safety
HRS-3: Implantable Cardioverter-Defibrillator (ICD)
Complications Rate
Patient Safety
HRS-12: Cardiac Tamponade and/or
Pericardiocentesis Following Atrial Fibrillation Ablation
Patient Safety
HRS-9: Infection within 180 Days of Cardiac
Implantable Electronic Device (CIED) Implantation,
Replacement, or Revision
Communication and Lung Cancer Reporting (Biopsy/Cytology Specimens)
Care Coordination
Communication and Lung Cancer Reporting (Resection Specimens)
Care Coordination

For 2015 MAV, CMS will not include measures, shown in Table 2, that are deemed to be generally or broadly
applicable to all or many Medicare patients and, therefore, potentially unreasonable to attribute to individual eligible
professionals or group practices using registry-based data for PQRS reporting. Other measures are not included in a
01/15/15
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2015 PQRS MEASURE-APPLICABILITY VALIDATION (MAV)
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cluster of closely clinically related measures for other clinical or technical reasons, such as the measure may not fit in
any cluster. The following is the list of registry-based measures that are not included within a clinical cluster.
Table 2: Measures Not Included Within a Cluster

Measure
Number
Measure 19
Measure 39
Measure 41
Measure 44
Measure 46
Measure 47
Measure 54
Measure 71
Measure 72
Measure 100
Measure 109
Measure 111
Measure 112
Measure 113
Measure 116
Measure 117
Measure 128
Measure 131
Measure 134
Measure 145
Measure 146
Measure 147
Measure 156
Measure 163
Measure 172
Measure 173
Measure 178
Measure 181
Measure 182
Measure 194
Measure 195
Measure 204
Measure 205
Measure 225
01/15/15
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Measure Name
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG
Surgery
Medication Reconciliation
Care Plan
Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain
Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Progesterone Receptor
(ER/PR) Positive Breast Cancer
Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category
(Regional Lymph Nodes) with Histologic Grade
Osteoarthritis (OA): Function and Pain Assessment
Pneumonia Vaccination Status for Older Adults
Breast Cancer Screening
Colorectal Cancer Screening
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
Diabetes: Eye Exam
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Pain Assessment and Follow-Up
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
Radiology: Inappropriate Use of "Probability Benign" Assessment Category in Screening
Mammograms
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone
Scintigraphy
Oncology: Radiation Dose Limits to Normal Tissues
Diabetes: Foot Exam
Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous
Arterial Venous (AV) Fistula
Preventative Care and Screening: Unhealthy Alcohol Use
Rheumatoid Arthritis (RA): Functional Status Assessment
Elder Maltreatment Screen and Follow-Up Plan
Functional Outcome Assessment
Oncology: Cancer Stage Documented
Radiology: Stenosis Measurement in Carotid Imaging Reports
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
Radiology: Reminder System for Screening Mammograms
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2015 PQRS MEASURE-APPLICABILITY VALIDATION (MAV)
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Measure
Number
Measure 236
Measure 238
Measure 243
Measure 249
Measure 250
Measure
Ultrasound
254
Measure 255
Measure 257
Measure 261
Measure 265
Measure 268
Measure 317
Measure 325
Measure 326
Measure 335
Measure 336
Measure 337
Measure 342
Measure 343
Measure 349
Measure 358
Measure 383
Measure 386
Measure 387
Measure 390
Measure 391
Measure 394
Measure 397
Measure 399
Measure 400
Measure 401
Measure 402

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Measure Name
Controlling High Blood Pressure
Use of High-Risk Medications in the Elderly
Cardiac Rehabilitation Patient Referral from an Outpatient Setting
Barrett’s Esophagus
Radical Prostatectomy Pathology Reporting
Ultrasound Determination of Pregnancy Location
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
Statin Therapy at Discharge after Lower Extremity Bypass (LEB)
Referral to Otologic Evaluation for Patients with Acute of Chronic Dizziness
Biopsy Follow-Up
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid
Conditions
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Maternity Care: Elective Delivery of Early Induction Without Medical Indication at > 37 and < 39
Weeks (Overuse)
Maternity Care: Post-Partum Follow-Up and Care Coordination
Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a
Biological Immune Response Modifier
Pain Brought Under Control Within 48 Hours
Screening Colonoscopy Adenoma Detection Rate
Optimal Vascular Care Composite
Patient-Centered Surgical Risk Assessment and Communication
Adherence to Antipsychotic Medications for Individuals with Schizophrenia
ALS Patient Care Preferences
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Discussion and Shared Decision Making Surrounding Treatment Options
Follow-up After Hospitalization for Mental Illness
Immunizations for Adolescent
Melanoma Reporting
Post-procedural Optimal medical therapy Composite (percutaneous coronary intervention)
Screening for Hepatitis C Virus (HCV) for Patients at High Risk
Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis
Tobacco Use and Help with Quitting Among Adolescents

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The following list of measures will be reported by measure group, EHR, or Web-Interface reporting only, therefore, is
not subject to registry MAV.
Table 3: Measures, Reported Measures Group, Electronic Health Record (EHR), or Web-Interface Only – Not Applicable to
Registry MAV

Measure Number
Measure 2
Measure 9
Measure 18
Measure 84
Measure 85
Measure 87
Measure 107
Measure 108
Measure 160
Measure 176
Measure 177
Measure 179
Measure 180
Measure 183
Measure 238
Measure 239
Measure 240
Measure 241
Measure 270
Measure 271
Measure 274
Measure 275
Measure 280
Measure 281
Measure 282
Measure 283
Measure 284
Measure 285
Measure 286
Measure 287
Measure 288
Measure 289
Measure 290
Measure 291
Measure 292
01/15/15
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Measure Name
Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL)
Anti-depressant Medication Management
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of
Severity of Retinopathy
Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
Hepatitis C: HCV Genotype Testing Prior to Treatment
Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After
Initiation of Treatment
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
Rheumatoid Arthritis (RA): Tuberculosis Screening
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Rheumatoid Arthritis (RA): Glucocorticoid Management
Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV)
Use of High-Risk Medications in the Elderly
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Childhood Immunization Status
Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100mg/dL)
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone
Loss Assessment
Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating 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
Dementia: Staging of Dementia
Dementia: Cognitive Assessment
Dementia: Functional Status Assessment
Dementia: Neuropsychiatric Symptom Assessment
Dementia: Management of Neuropsychiatric Symptoms
Dementia: Screening for Depressive Symptoms
Dementia: Counseling Regarding Safety Concerns
Dementia: Counseling Regarding Risks of Driving
Dementia: Caregiver Education and Support
Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review
Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
Parkinson’s Disease: Querying about Sleep Disturbances
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Measure Number
Measure 293
Measure 294
Measure 305
Measure 309
Measure 310
Measure 311
Measure 312
Measure 316
Measure 318
Measure 319
Measure 321
Measure 338
Measure 339
Measure 340
Measure 350
Measure 351
Measure 352
Measure 353
Measure 354
Measure 355
Measure 356
Measure 357
Measure 359
Measure 360
Measure 361
Measure 362
Measure 363
Measure 364
Measure 365
Measure 366
Measure 367
Measure 368
Measure 369
Measure 370
Measure 371
Measure 372
Measure 373
Measure 374
01/15/15
Version 2.0

Measure Name
Parkinson’s Disease: Rehabilitative Therapy Options
Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Cervical Cancer Screening
Chlamydia Screening for Women
Use of Appropriate Medications for Asthma
Use of Imaging Studies for Low Back Pain
Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test
Performed: AND Risk-Stratified Fasting LDL-C
Falls: Screening for Future Fall Risk
Diabetes Composite: Optimal Diabetes Care
CG-CAHPS Clinician/Group Survey
HIV Viral Load Suppression
Prescription of HIV Antiretroviral Therapy
HIV Medical Visit Frequency
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
Anastomotic Leak Intervention
Unplanned Reoperation within the 30 Day Postoperative Period
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Surgical Site Infection (SSI)
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for
Computed Tomography (CT) Imaging Description
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging
Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available
for Patient Follow-up and Comparison Purposes
Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT)
Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for
Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
Hemoglobin A1c Test for Pediatric Patients
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD)
Medication
Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use
HIV/AIDS: Medical Visit
Pregnant women that had HBsAg testing
Depression Remission at Twelve Months
Depression Utilization of the PHQ-9 Tool
Maternal Depression Screening
Hypertension: Improvement in Blood Pressure
Closing the referral loop: receipt of specialist report
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Measure Number
Measure 375
Measure 376
Measure 377
Measure 378
Measure 379
Measure 380
Measure 381
Measure 382

01/15/15
Version 2.0

Measure Name
Functional Status Assessment for Knee Replacement
Functional Status Assessment for Hip Replacement
Functional Status Assessment for Complex Chronic Conditions
Children Who Have Dental Decay or Cavities
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range
HIV/AIDS: RNA Control for Patients with HIV
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

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