Form CMS-10621 List of Quality Performance Category Measures

APPENDIX A: PROPOSED MEASURES FOR MIPS QUALITY PERFORMANCE CATEGORY

TABLE A: Proposed Individual Quality Measures Available for MIPS Reporting in 2017 (Existing Measures Finalized in CMS-1631-FC). The 2016 PQRS Measures Specifications Supporting Documents can be found at the following link: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/measurescodes.html.

Note: Existing measures with proposed substantive changes are noted with an asterisk (*), new proposed measures are noted with a plus symbol (+), core measures as agreed upon by Core Measure Collaborative are noted with the symbol (§), high priority measures are noted with an exclamation point (!), and high priority measures that are appropriate use measures are noted with a double exclamation point (!!), in the “MIPS ID Number” column.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	National Quality Strategy Domain		Data submission Method	Measure Type	Measure Title and Description¥	Measure Steward
* § !	0059/001	122v4	Effective Clinical Care		Claims, Web Interface, Registry, EHR	Intermediate Outcome	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%): Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.	National Committee for Quality Assurance
§	0081/005	135v4	Effective Clinical Care		Registry, EHR	Process	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* §	0067/006	N/A	Effective Clinical Care		Registry	Process	Chronic Stable Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel.	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
§	007 0/007	145v4	Effective Clinical Care		Registry, EHR	Process	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.	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* §	0083/008	144v4	Effective Clinical Care		Registry, EHR	Process	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
	0105/ 009	128v4	Effective Clinical Care		EHR	Process	Anti-Depressant Medication Management: Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).	National Committee for Quality Assurance
	0086/012	143v4	Effective Clinical Care		Claims, Registry, EHR	Process	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
	0087/014	N/A	Effective Clinical Care		Claims, Registry	Process	Age-Related Macular Degeneration (AMD): Dilated Macular Examination: Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months.	American Academy of Ophthalmology
	0088/018	167v4	Effective Clinical Care		EHR	Process	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.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0089/019	142v4	Communication and Care Coordination		Claims, Registry, EHR	Process	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!!	0268/021	N/A	Patient Safety		Claims, Registry	Process	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0239/023	N/A	Patient Safety		Claims, Registry	Process	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients): Percentage of surgical 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.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0045/024	N/A	Communication and Care Coordination		Claims, Registry	Process	Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older: Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
	0325/032	N/A	Effective Clinical Care		Claims, Registry	Process	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) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an antithrombotic at discharge.	American Academy of Neurology
	0046/039	N/A	Effective Clinical Care		Claims, Registry	Process	Screening for Osteoporosis for Women Aged 65-85 Years of Age: Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.	National Committee for Quality Assurance / American Medical Association-Physician Consortium for Performance Improvement
	0134/043	N/A	Effective Clinical Care		Registry	Process	Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft.	Society of Thoracic Surgeons
	0236/044	N/A	Effective Clinical Care		Registry	Process	Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery: Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
* § !	0097/046	N/A	Communication and Care Coordination		Claims, Web Interface, Registry	Process	Medication Reconciliation Post-Discharge: The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group: • Reporting Criteria 1: 18-64 years of age • Reporting Criteria 2: 65 years and older • Total Rate: All patients 18 years of age and older.	National Committee for Quality Assurance / American Medical Association-Physician Consortium for Performance Improvement
!	0326/047	N/A	Communication and Care Coordination		Claims, Registry	Process	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.	National Committee for Quality Assurance / American Medical Association-Physician Consortium for Performance Improvement
	N/A/048	N/A	Effective Clinical Care		Claims, Registry	Process	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.	National Committee for Quality Assurance / American Medical Association-Physician Consortium for Performance Improvement
!	N/A/050	N/A	Person and Caregiver-Centered Experience and Outcomes		Claims, Registry	Process	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.	National Committee for Quality Assurance / American Medical Association-Physician Consortium for Performance Improvement
	0091/051	N/A	Effective Clinical Care		Claims, Registry	Process	Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented.	American Thoracic Society
	0102/052	N/A	Effective Clinical Care		Claims, Registry	Process	Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy: Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1 less than 60% predicted and have symptoms who were prescribed an inhaled bronchodilator.	American Thoracic Society
!!	0069/065	154v4	Efficiency and Cost Reduction		Registry, EHR	Process	Appropriate Treatment for Children with Upper Respiratory Infection (URI): Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.	National Committee for Quality Assurance
* !!	N/A/066	N/A	Efficiency and Cost Reduction		Registry, EHR	Process	Appropriate Testing for Children with Pharyngitis: Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.	National Committee for Quality Assurance
	0377/067	N/A	Effective Clinical Care		Registry	Process	Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemia: Baseline Cytogenetic Testing Performed on Bone Marrow: Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.	American Medical Association-Physician Consortium for Performance Improvement/ American Society of Hematology
	0378/068	N/A	Effective Clinical Care		Registry	Process	Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy: Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy.	American Medical Association-Physician Consortium for Performance Improvement/ American Society of Hematology
	0380/069	N/A	Effective Clinical Care		Registry	Process	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.	American Medical Association-Physician Consortium for Performance Improvement/ American Society of Hematology
	0379/070	N/A	Effective Clinical Care		Registry	Process	Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry: Percentage of patients aged 18 years and older seen within a 12 month reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart.	American Medical Association-Physician Consortium for Performance Improvement/ American Society of Hematology
!	N/A/076	N/A	Patient Safety		Claims, Registry	Process	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections: Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.	American Society of Anesthesiologists
!!	0653/091	N/A	Effective Clinical Care		Claims, Registry	Process	Acute Otitis Externa (AOE): Topical Therapy: Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.	American Academy of Otolaryngology-Head and Neck Surgery
!!	0654/093	N/A	Efficiency and Cost Reduction		Claims, Registry	Process	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.	American Academy of Otolaryngology-Head and Neck Surgery
	0391/099	N/A	Effective Clinical Care		Claims, Registry	Process	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.	College of American Pathologists
	0392/100	N/A	Effective Clinical Care		Claims, Registry	Process	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.	College of American Pathologists
* § !!	0389/102	129v5	Efficiency and Cost Reduction		Registry, EHR	Process	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.	American Medical Association-Physician Consortium for Performance Improvement
	0390/104	N/A	Effective Clinical Care		Registry	Process	Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist).	American Medical Association-Physician Consortium for Performance Improvement/ American Urological Association Education and Research
	0104/ 107	161v4	Effective Clinical Care		EHR	Process	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.	American Medical Association-Physician Consortium for Performance Improvement
!	N/A/109	N/A	Person and Caregiver-Centered Experience and Outcomes		Claims, Registry	Process	Osteoarthritis (OA): Function and Pain Assessment: Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain.	American Academy of Orthopedic Surgeons
	0041/110	147v5	Community/Population Health		Claims, Web Interface, Registry, EHR	Process	Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.	American Medical Association-Physician Consortium for Performance Improvement
	0043/111	127v4	Community/Population Health		Claims, Web Interface, Registry, EHR	Process	Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.	National Committee for Quality Assurance
* §	2372/112	125v4	Effective Clinical Care		Claims, Web Interface, Registry, EHR	Process	Breast Cancer Screening: Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer.	National Committee for Quality Assurance
§	0034/113	130v4	Effective Clinical Care		Claims, Web Interface, Registry, EHR	Process	Colorectal Cancer Screening: Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer.	National Committee for Quality Assurance
§ !!	0058/116	N/A	Efficiency and Cost Reduction		Registry	Process	Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use: Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode.	National Committee for Quality Assurance
§	0055/117	131v4	Effective Clinical Care		Claims, Web Interface, Registry, EHR	Process	Diabetes: Eye Exam: Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period.	National Committee for Quality Assurance
* §	0066/118	N/A	Effective Clinical Care		Registry	Process	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy.	American College of Cardiology/American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
* §	0062/119	134v4	Effective Clinical Care		Registry, EHR	Process	Diabetes: Medical Attention for Nephropathy: The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period	National Committee for Quality Assurance
!	N/A/122	N/A	Effective Clinical Care		Registry	Intermediate Outcome	Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR ≥ 140/90 mmHg with a documented plan of care.	Renal Physicians Association
	0417/126	N/A	Effective Clinical Care		Registry	Process	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.	American Podiatric Medical Association
	0416/127	N/A	Effective Clinical Care		Registry	Process	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.	American Podiatric Medical Association
* §	0421/128	69v4	Community/Population Health		Claims, Web Interface, Registry, EHR	Process	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 – 64 years BMI ≥ 18.5 and < 25 kg/m2.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
* !	0419/130	68v5	Patient Safety		Claims, Registry, EHR	Process	Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	0420/131	N/A	Communication and Care Coordination		Claims, Registry	Process	Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
*	0418/134	2v5	Community/Population Health		Claims, Web Interface, Registry, EHR	Process	Preventive Care and Screening: Screening for Depression and Follow-Up Plan: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	0650/137	N/A	Communication and Care Coordination		Registry	Structure	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.	American Academy of Dermatology/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/138	N/A	Communication and Care Coordination		Registry	Process	Melanoma: Coordination of Care: Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.	American Academy of Dermatology/ American Medical Association-Physician Consortium for Performance Improvement
	0566/140	N/A	Effective Clinical Care		Claims, Registry	Process	Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement: Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD.	American Academy of Ophthalmology
!	0563/141	N/A	Communication and Care Coordination		Claims, Registry	Outcome	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months.	American Academy of Ophthalmology
§ !	0384/143	157v4	Person and Caregiver-Centered Experience and Outcomes		Registry, EHR	Process	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.	American Medical Association-Physician Consortium for Performance Improvement
!	0383/144	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Process	Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.	American Society of Clinical Oncology
!!	N/A/145	N/A	Patient Safety		Claims, Registry	Process	Radiology: Exposure Time Reported for Procedures Using Fluoroscopy: Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available).	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
!	0508/146	N/A	Efficiency and Cost Reduction		Claims, Registry	Process	Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening: Percentage of final reports for screening mammograms that are classified as “probably benign”.	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/147	N/A	Communication and Care Coordination		Claims, Registry	Process	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.	American Medical Association-Physician Consortium for Performance Improvement/ Society of Nuclear Medicine and Molecular Imaging
!	0101/154	N/A	Patient Safety		Claims, Registry	Process	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.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	0101/155	N/A	Communication and Care Coordination		Claims, Registry	Process	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.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!!	0382/156	N/A	Patient Safety		Claims, Registry	Process	Oncology: Radiation Dose Limits to Normal Tissues: Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.	American Society for Radiation Oncology
* §	0405/160	52v4	Effective Clinical Care		EHR	Process	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis.	National Committee for Quality Assurance
* §	0056/163	123v4	Effective Clinical Care		EHR	Process	Diabetes: Foot Exam: Percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year.	National Committee for Quality Assurance
!	0129/164	N/A	Effective Clinical Care		Registry	Outcome	Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.	Society of Thoracic Surgeons
* !	0130/165	N/A	Effective Clinical Care		Registry	Outcome	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.	Society of Thoracic Surgeons
* !	0131/166	N/A	Effective Clinical Care		Registry	Outcome	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.	Society of Thoracic Surgeons
* !	0114/167	N/A	Effective Clinical Care		Registry	Outcome	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.	Society of Thoracic Surgeons
* !	0115/168	N/A	Effective Clinical Care		Registry	Outcome	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.	Society of Thoracic Surgeons
*	N/A/176	N/A	Effective Clinical Care		Registry	Process	Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).	American College of Rheumatology
*	N/A/ 177	N/A	Effective Clinical Care		Registry	Process	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months.	American College of Rheumatology
	N/A/178	N/A	Effective Clinical Care		Registry	Process	Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.	American College of Rheumatology
*	N/A/179	N/A	Effective Clinical Care		Registry	Process	Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.	American College of Rheumatology
*	N/A/180	N/A	Effective Clinical Care		Registry	Process	Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.	American College of Rheumatology
!	N/A/181	N/A	Patient Safety		Claims, Registry	Process	Elder Maltreatment Screen and Follow-Up Plan: Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
!	2624/182	N/A	Communication and Care Coordination		Claims, Registry	Process	Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
§ !!	0659/185	N/A	Communication and Care Coordination		Claims, Registry	Process	Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy.	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
*	N/A/187	N/A	Effective Clinical Care		Registry	Process	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.	American Heart Association/ American Society of Anesthesiologists/ The Joint Commission
!	0565/191	133v4	Effective Clinical Care		Registry, EHR	Outcome	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.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0564/192	132v4	Patient Safety		Registry, EHR	Outcome	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.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
	0507/195	N/A	Effective Clinical Care		Claims, Registry	Process	Radiology: Stenosis Measurement in Carotid Imaging Reports: Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
* §	0068/204	164v4	Effective Clinical Care		Claims, Web Interface, Registry, EHR	Process	Ischemic (IVD): Use of Aspirin or Another Antiplatelet: Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antiplatelet during the measurement period.	National Committee for Quality Assurance
§	0409/205	N/A	Effective Clinical Care		Registry	Process	HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
* !	0422/217	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with Knee Impairments: A self-report measure of change in functional status for patients 18 year+ with knee impairments. The change in functional status assessed using FOTO’s (knee) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
* !	0423/218	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with Hip Impairments: A self-report measure of change in functional status for patients 18 years+ with hip impairments. The change in functional status assessed using FOTO’s (hip) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
* !	0424/219	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with Foot and Ankle Impairments: A self-report measure of change in functional status for patients 18 years+ with foot and ankle impairments. The change in functional status assessed using FOTO’s (foot and ankle) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
* !	0425/220	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with Lumbar Impairments: A self-report outcome measure of functional status for patients 18 years+ with lumbar impairments. The change in functional status assessed using FOTO’s (lumbar) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
* !	0426/221	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with Shoulder Impairments: A self-report outcome measure of change in functional status for patients 18 years+ with shoulder impairments. The change in functional status assessed using FOTO’s (shoulder) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
* !	0427/222	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with Elbow, Wrist and Hand Impairments: A self-report outcome measure of functional status for patients 18 years+ with elbow, wrist and hand impairments. The change in functional status assessed using FOTO’s (elbow, wrist and hand) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
* !	0428/223	N/A	Communication and Care Coordination		Registry	Outcome	Functional Status Change for Patients with General Orthopedic Impairments: A self-report outcome measure of functional status for patients 18 years+ with general orthopedic impairments. The change in functional status assessed using FOTO (general orthopedic) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.	Focus on Therapeutic Outcomes, Inc.
!!	0562/224	N/A	Efficiency and Cost Reduction		Registry	Process	Melanoma: Overutilization of Imaging Studies in Melanoma: Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.	American Academy of Dermatology/ American Medical Association-Physician Consortium for Performance Improvement
!	0509/225	N/A	Communication and Care Coordination		Claims, Registry	Structure	Radiology: Reminder System for Screening Mammograms: Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
§	0028/226	138v4	Community/Population Health		Claims, Web Interface, Registry, EHR	Process	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.	American Medical Association-Physician Consortium for Performance Improvement
§ !	0018/236	165v4	Effective Clinical Care		Claims, Web Interface, Registry, EHR	Intermediate Outcome	Controlling High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.	National Committee for Quality Assurance
!	0022/238	156v4	Patient Safety		Registry, EHR	Process	Use of High-Risk Medications in the Elderly: Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.	National Committee for Quality Assurance
	0024/239	155v4	Community/Population Health	EHR		Process	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity.	National Committee for Quality Assurance
	0038/240	117v4	Community/Population Health		EHR	Process	Childhood Immunization Status: Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.	National Committee for Quality Assurance
!	0643/243	N/A	Communication and Care Coordination		Registry	Process	Cardiac Rehabilitation Patient Referral from an Outpatient Setting: Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.	American College of Cardiology Foundation/ American Heart Association
	1854/249	N/A	Effective Clinical Care		Claims, Registry	Structure	Barrett's Esophagus: Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia.	College of American Pathologists
§	1853/250	N/A	Effective Clinical Care		Claims, Registry	Structure	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.	College of American Pathologists
	1855/251	N/A	Effective Clinical Care		Claims, Registry	Structure	Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients: This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer.	College of American Pathologists
	0651/254	N/A	Effective Clinical Care		Claims, Registry	Process	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.	American College of Emergency Physicians
	N/A/255	N/A	Effective Clinical Care		Claims, Registry	Process	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).	American College of Emergency Physicians
	1519/257	N/A	Effective Clinical Care		Registry	Process	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.	Society for Vascular Surgeons
!	N//A/258	N/A	Patient Safety		Registry	Outcome	Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7): Percent of patients undergoing open repair of small or moderate sized non-ruptured abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7).	Society for Vascular Surgeons
!	N/A/259	N/A	Patient Safety		Registry	Outcome	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).	Society for Vascular Surgeons
!	N/A/260	N/A	Patient Safety		Registry	Outcome	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2.	Society for Vascular Surgeons
!	N/A/261	N/A	Communication and Care Coordination		Claims, Registry	Process	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.	Audiology Quality Consortium
!	N/A/262	N/A	Patient Safety		Registry	Process	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.	American Society of Breast Surgeons
	N/A/263	N/A	Effective Clinical Care		Registry	Process	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.	American Society of Breast Surgeons
	N/A/264	N/A	Effective Clinical Care		Registry	Process	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.	American Society of Breast Surgeons
!	N/A/265	N/A	Communication and Care Coordination		Registry	Process	Biopsy Follow-Up: Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician.	American Academy of Dermatology
*	1814/268	N/A	Effective Clinical Care		Claims, Registry	Process	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy: All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year.	American Academy of Neurology
§	N/A/271	N/A	Effective Clinical Care		Registry	Process	Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment: Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year.	American Gastroenterological Association
§	N/A/275	N/A	Effective Clinical Care		Registry	Process	Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy.	American Gastroenterological Association
*	N/A/276	N/A	Effective Clinical Care		Registry	Process	Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness.	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
*	N/A/277	N/A	Effective Clinical Care		Registry	Process	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.	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
*	N/A/278	N/A	Effective Clinical Care		Registry	Process	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.	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
*	N/A/279	N/A	Effective Clinical Care		Registry	Process	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.	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
	N/A/281	149v4	Effective Clinical Care		EHR	Process	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.	American Medical Association-Physician Consortium for Performance Improvement
*	N/A/282	N/A	Effective Clinical Care		Registry	Process	Dementia: Functional Status Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period.	American Academy of Neurology/ American Psychological Association
*	N/A/283	N/A	Effective Clinical Care		Registry	Process	Dementia: Neuropsychiatric Symptom Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period.	American Academy of Neurology/ American Psychological Association
*	N/A/284	N/A	Effective Clinical Care		Registry	Process	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.	American Academy of Neurology/ American Psychological Association
* !	N/A/286	N/A	Patient Safety		Registry	Process	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.	American Academy of Neurology/ American Psychological Association
* !	N/A/288	N/A	Communication and Care Coordination		Registry	Process	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.	American Academy of Neurology/ American Psychological Association
*	N/A/290	N/A	Effective Clinical Care		Registry	Process	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.	American Academy of Neurology
*	N/A/291	N/A	Effective Clinical Care		Registry	Process	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.	American Academy of Neurology
* !	N/A/293	N/A	Communication and Care Coordination		Registry	Process	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.	American Academy of Neurology
* !	N/A/294	N/A	Communication and Care Coordination		Registry	Process	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.	American Academy of Neurology
!	1536/303	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Outcome	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.	American Academy of Ophthalmology
!	N/A/304	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Outcome	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.	American Academy of Ophthalmology
	0004/305	137v4	Effective Clinical Care		EHR	Process	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.	National Committee for Quality Assurance
* §	0032/309	124v4	Effective Clinical Care		EHR	Process	Cervical Cancer Screening: Percentage of women 21-64 years of age, who were screened for cervical cancer using either of the following criteria. • Women age 21–64 who had cervical cytology performed every 3 years • Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years	National Committee for Quality Assurance
	0033/310	153v4	Community/Population Health		EHR	Process	Chlamydia Screening for Women: Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.	National Committee for Quality Assurance
§ !!	0052/312	166v5	Efficiency and Cost Reduction		EHR	Process	Use of Imaging Studies for Low Back Pain: Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.	National Committee for Quality Assurance
!	N/A/316	61v5 & 64v5	Effective Clinical Care		EHR	Intermediate Outcome	Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting LDL-C: Percentage of patients aged 20 through 79 years whose risk factors* have been assessed and a fasting LDL test has been performed AND percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal. *There are three criteria for this measure based on the patient’s risk category. 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent OR 10-Year Framingham Risk >20% 2. Moderate Level of Risk: Multiple (2+) Risk Factors OR 10-Year Framingham Risk 10-20% 3. Lowest Level of Risk: 0 or 1 Risk Factor OR 10-Year Framingham Risk <10%.	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
*	N/A/317	22v4	Community/Population Health		Claims, Registry, EHR	Process	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	0101/318	139v4	Patient Safety		Web Interface, EHR	Process	Falls: Screening for Fall Risk: Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period.	National Committee for Quality Assurance
§ !!	0658/320	N/A	Communication and Care Coordination		Claims, Registry	Process	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
§ !	0005 & 0006/321	N/A	Person and Caregiver-Centered Experience and Outcomes		CMS-approved Survey Vendor	Patient Engagement/Experience	CAHPS for MIPS Clinician/Group Survey: Summary Survey Measures may include: • Getting Timely Care, Appointments, and Information; • How well Providers Communicate; • Patient’s Rating of Provider; • Access to Specialists; • Health Promotion and Education; • Shared Decision-Making; • Health Status and Functional Status; • Courteous and Helpful Office Staff; • Care Coordination; • Between Visit Communication; • Helping You to Take Medication as Directed; and • Stewardship of Patient Resources.	Agency for Healthcare Research & Quality
!!	N/A/322	N/A	Efficiency and Cost Reduction		Registry	Efficiency	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients: Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period.	American College of Cardiology
!!	N/A/323	N/A	Efficiency and Cost Reduction		Registry	Efficiency	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI): Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status.	American College of Cardiology
!!	N/A/324	N/A	Efficiency and Cost Reduction		Registry	Efficiency	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients: Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.	American College of Cardiology
!	N/A/325	N/A	Communication and Care Coordination		Registry	Process	Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions: Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.	American Psychiatric Association/American Medical Association-Physician Consortium for Performance Improvement
§	1525/326	N/A	Effective Clinical Care		Claims, Registry	Process	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy: Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism.	American College of Cardiology/American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
* !	N/A/327	N/A	Effective Clinical Care		Registry	Process	Pediatric Kidney Disease: Adequacy of Volume Management: Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist.	Renal Physicians Association
!	1667/328	N/A	Effective Clinical Care		Registry	Intermediate Outcome	Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/Dl: Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL.	Renal Physicians Association
!	N/A/329	N/A	Effective Clinical Care		Registry	Outcome	Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis: Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated.	Renal Physicians Association
!!	N/A/330	N/A	Patient Safety		Registry	Outcome	Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days: Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter.	Renal Physicians Association
!!	N/A/331	N/A	Efficiency and Cost Reduction		Registry	Process	Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse): Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/332	N/A	Efficiency and Cost Reduction		Registry	Process	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use): Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis.	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/333	N/A	Efficiency and Cost Reduction		Registry	Efficiency	Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse): Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis.	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/334	N/A	Efficiency and Cost Reduction		Registry	Efficiency	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse): Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis.	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/335	N/A	Patient Safety		Registry	Outcome	Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks: Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication.	American Medical Association-Physician Consortium for Performance Improvement
!	N/A/336	N/A	Communication and Care Coordination		Registry	Process	Maternity Care: Post-Partum Follow-Up and Care Coordination: Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning.	American Medical Association-Physician Consortium for Performance Improvement
	N/A/337	N/A	Effective Clinical Care		Registry	Process	Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier: Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.	American Academy of Dermatology
* § !	2082/338	N/A	Effective Clinical Care		Registry	Outcome	HIV Viral Load Suppression: The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.	Health Resources and Services Administration
* § !	2079/340	N/A	Efficiency and Cost Reduction		Registry	Process	HIV Medical Visit Frequency: Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.	Health Resources and Services Administration
!	N/A/342	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Outcome	Pain Brought Under Control Within 48 Hours: Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours.	National Hospice and Palliative Care Organization
§ !	N/A/343	N/A	Effective Clinical Care		Registry	Outcome	Screening Colonoscopy Adenoma Detection Rate Measure: The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy.	American College of Gastroenterology/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy
!	N/A/344	N/A	Effective Clinical Care		Registry	Outcome	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.	Society for Vascular Surgeons
!	1543/345	N/A	Effective Clinical Care		Registry	Outcome	Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS): Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital.	Society for Vascular Surgeons
!	1540/346	N/A	Effective Clinical Care		Registry	Outcome	Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA): Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital.	Society for Vascular Surgeons
!	1534/347	N/A	Patient Safety		Registry	Outcome	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital: Percent of patients undergoing endovascular repair of small or moderate abdominal aortic aneurysms (AAA) who die while in the hospital.	Society for Vascular Surgeons
!	N/A/348	N/A	Patient Safety		Registry	Outcome	HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate: Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD.	The Heart Rhythm Society
* !	N/A/350	N/A	Communication and Care Coordination		Registry	Process	Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy: Percentage of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.	American Association of Hip and Knee Surgeons
* !	N/A/351	N/A	Patient Safety		Registry	Process	Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation: Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).	American Association of Hip and Knee Surgeons
* !	N/A/352	N/A	Patient Safety		Registry	Process	Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet: Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet.	American Association of Hip and Knee Surgeons
* !	N/A/353	N/A	Patient Safety		Registry	Process	Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report: Percentage of patients regardless of age or gender undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant.	American Association of Hip and Knee Surgeons
* !	N/A/354	N/A	Patient Safety		Registry	Outcome	Anastomotic Leak Intervention: Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.	American College of Surgeons
* !	N/A/355	N/A	Patient Safety		Registry	Outcome	Unplanned Reoperation within the 30 Day Postoperative Period: Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.	American College of Surgeons
* !	N/A/356	N/A	Effective Clinical Care		Registry	Outcome	Unplanned Hospital Readmission within 30 Days of Principal Procedure: Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.	American College of Surgeons
* !	N/A/357	N/A	Effective Clinical Care		Registry	Outcome	Surgical Site Infection (SSI): Percentage of patients aged 18 years and older who had a surgical site infection (SSI).	American College of Surgeons
!	N/A/358	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Process	Patient-Centered Surgical Risk Assessment and Communication: Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.	American College of Surgeons
* !	N/A/359	N/A	Communication and Care Coordination		Registry	Process	Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description: Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems.	American College of Radiology
* !!	N/A/360	N/A	Patient Safety		Registry	Process	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies: Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.	American College of Radiology
* !	N/A/361	N/A	Patient Safety		Registry	Structure	Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry: Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements.	American College of Radiology
* !	N/A/362	N/A	Communication and Care Coordination		Registry	Structure	Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes: Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study.	American College of Radiology
* !	N/A/363	N/A	Communication and Care Coordination		Registry	Structure	Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive: Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed.	American College of Radiology
* !!	N/A/364	N/A	Communication and Care Coordination		Registry	Process	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines: Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors.	American College of Radiology
	0108/366	136v5	Effective Clinical Care		EHR	Process	ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication: Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.	National Committee for Quality Assurance
	N/A/367	169v4	Effective Clinical Care		EHR	Process	Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use: Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.	Center for Quality Assessment and Improvement in Mental Health
	N/A/369	158v4	Effective Clinical Care		EHR	Process	Pregnant Women that had HBsAg Testing: This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.	OptumInsight
* § !	0710/370	159v4	Effective Clinical Care		Web Interface, Registry, EHR	Outcome	Depression Remission at Twelve Months: Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days) after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.	Minnesota Community Measurement
	0712/371	160v4	Effective Clinical Care		EHR	Process	Depression Utilization of the PHQ-9 Tool: Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4 month period in which there was a qualifying visit.	Minnesota Community Measurement
	N/A/372	82v3	Community/Population Health		EHR	Process	Maternal Depression Screening: The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child’s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.	National Committee for Quality Assurance
!	N/A/373	65v5	Effective Clinical Care		EHR	Intermediate Outcome	Hypertension: Improvement in Blood Pressure: Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.	Centers for Medicare & Medicaid Services/National Committee for Quality Assurance
!	N/A/374	50v4	Communication and Care Coordination		EHR	Process	Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.	Centers for Medicare & Medicaid Services/ Mathematica
* !	N/A/375	66v4	Person and Caregiver-Centered Experience and Outcomes		EHR	Process	Functional Status Assessment for Total Knee Replacement: Percentage of patients aged 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments.	Centers for Medicare & Medicaid Services/National Committee for Quality Assurance
* !	N/A/376	56v4	Person and Caregiver-Centered Experience and Outcomes		EHR	Process	Functional Status Assessment for Total Hip Replacement: Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments.	Centers for Medicare & Medicaid Services/National Committee for Quality Assurance
* !	N/A/377	90v4	Person and Caregiver-Centered Experience and Outcomes		EHR	Process	Functional Status Assessment for Patients with Congestive Heart Failure: Percentage of patients aged 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.	Centers for Medicare & Medicaid Services/ Mathematica
!	N/A/378	75v4	Community/Population Health		EHR	Outcome	Children Who Have Dental Decay or Cavities: Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period.	Centers for Medicare & Medicaid Services/ Mathematica
	N/A/379	74v5	Effective Clinical Care		EHR	Process	Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.	Centers for Medicare & Medicaid Services/National Committee for Quality Assurance
!	1365/382	177v4	Patient Safety		EHR	Process	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.	American Medical Association-Physician Consortium for Performance Improvement
!	1879/383	N/A	Patient Safety		Registry	Intermediate Outcome	Adherence to Antipsychotic Medications for Individuals with Schizophrenia: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).	Health Services Advisory Group/ Centers for Medicare & Medicaid Services
!	N/A/384	N/A	Effective Clinical Care		Registry	Outcome	Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery: Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.	American Academy of Ophthalmology
!	N/A/385	N/A	Effective Clinical Care		Registry	Outcome	Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery: Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.	American Academy of Ophthalmology/ The Australian Council on Healthcare Standards
!	N/A/386	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Process	Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences: Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually.	American Academy of Neurology
	N/A/387	N/A	Effective Clinical Care		Registry	Process	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period.	American Medical Association-Physician Consortium for Performance Improvement
!	N/A/388	N/A	Patient Safety		Registry	Outcome	Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy: Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy.	American Academy of Ophthalmology/American College of Healthcare Sciences
!	N/A/389	N/A	Effective Clinical Care		Registry	Outcome	Cataract Surgery: Difference Between Planned and Final Refraction: Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.	American Academy of Ophthalmology/American College of Healthcare Sciences
!	N/A/390	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Process	Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment.	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
!	0576/391	N/A	Communication and Care Coordination		Registry	Process	Follow-Up After Hospitalization for Mental Illness (FUH): The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.	National Committee for Quality Assurance
!	2474/392	N/A	Patient Safety		Registry	Outcome	HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation: Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender: • Reporting Age Criteria 1: Females less than 65 years of age • Reporting Age Criteria 2: Males less than 65 years of age • Reporting Age Criteria 3: Females 65 years of age and older • Reporting Age Criteria 4: Males 65 years of age and older	The Heart Rhythm Society
!	N/A/393	N/A	Patient Safety		Registry	Outcome	HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision: Infection rate following CIED device implantation, replacement, or revision.	The Heart Rhythm Society
	1407/394	N/A	Community/Population Health		Registry	Process	Immunizations for Adolescents: The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.	National Committee for Quality Assurance
!	N/A/395	N/A	Communication and Care Coordination		Claims, Registry	Process	Lung Cancer Reporting (Biopsy/Cytology Specimens): Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary nonsmall cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report.	College of American Pathologists
!	N/A/396	N/A	Communication and Care Coordination		Claims, Registry	Process	Lung Cancer Reporting (Resection Specimens): Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type.	College of American Pathologists
!	N/A/397	N/A	Communication and Care Coordination		Claims, Registry	Process	Melanoma Reporting: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate.	College of American Pathologists
!	N/A/398	N/A	Effective Clinical Care		Registry	Outcome	Optimal Asthma Control: Patients ages 5-50 (pediatrics ages 5-17) whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools.	Minnesota Community Measurement
§	N/A/400	N/A	Effective Clinical Care		Registry	Process	One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received a one-time screening for HCV infection.	American Medical Association-Physician Consortium for Performance Improvement
§	N/A/401	N/A	Effective Clinical Care		Registry	Process	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period.	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
	N/A/402	N/A	Community/Population Health		Registry	Process	Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.	National Committee for Quality Assurance/National Collaborative for Innovation in Quality Measurement
!	N/A/403‡	N/A	Person and Caregiver-Centered Experience and Outcomes		Registry	Process	Adult Kidney Disease: Referral to Hospice: Percentage of patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care.	Renal Physicians Association/American Medical Association-Physician Consortium for Performance Improvement
!	N/A/404‡	N/A	Effective Clinical Care		Registry	Intermediate Outcome	Anesthesiology Smoking Abstinence: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.	American Society of Anesthesiologists
	N/A/405‡	N/A	Effective Clinical Care		Claims, Registry	Process	Appropriate Follow-up Imaging for Incidental Abdominal Lesions: Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: •Liver lesion < 0.5 cm •Cystic kidney lesion < 1.0 cm •Adrenal lesion < 1.0 cm	American College of Radiology
!!	N/A/406 ‡	N/A	Effective Clinical Care		Claims, Registry	Process	Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients: Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.	American College of Radiology
!!	N/A/407‡	N/A	Effective Clinical Care		Claims, Registry	Process	Appropriate Treatment of MSSA Bacteremia: Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy.	Infectious Disease Society of America
	N/A/408‡	N/A	Effective Clinical Care		Registry	Process	Opioid Therapy Follow-up Evaluation: All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record.	American Academy of Neurology
!	N/A/409‡	N/A	Effective Clinical Care		Registry	Outcome	Clinical Outcome Post Endovascular Stroke Treatment: Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention.	Society of Interventional Radiology
!	N/A/410‡	N/A	Person and Caregiver-Centered Experience and Outcomes		Claims, Registry	Outcome	Psoriasis: Clinical Response to Oral Systemic or Biologic Medications: Percentage of psoriasis patients receiving oral systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.	American Academy of Dermatology
!	0711/411‡	N/A	Communication and Care Coordination		Registry	Outcome	Depression Remission at Six Months: Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.	Minnesota Community Measurement
	N/A/412‡	N/A	Effective Clinical Care		Registry	Process	Documentation of Signed Opioid Treatment Agreement: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.	American Academy of Neurology
!	N/A/413‡	N/A	Effective Clinical Care		Registry	Intermediate Outcome	Door to Puncture Time for Endovascular Stroke Treatment: Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours.	Society of Interventional Radiology
	N/A/414‡	N/A	Effective Clinical Care		Registry	Process	Evaluation or Interview for Risk of Opioid Misuse: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record.	American Academy of Neurology
!	N/A/415‡	N/A	Efficiency and Cost Reduction		Claims, Registry	Efficiency	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older: Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.	American College of Emergency Physicians
!!	N/A/416‡	N/A	Efficiency and Cost Reduction		Claims, Registry	Efficiency	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years: Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network prediction rules for traumatic brain injury.	American College of Emergency Physicians
!	1523/417‡	N/A	Patient Safety		Registry	Outcome	Rate of Open Repair of Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive: Percentage of patients undergoing open repair of abdominal aortic aneurysms (AAA) who are discharged alive.	Society for Vascular Surgeons
	0053/418‡	N/A	Effective Clinical Care		Claims, Registry	Process	Osteoporosis Management in Women Who Had a Fracture: The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!!	N/A/419‡	N/A	Efficiency and Cost Reduction		Claims, Registry	Efficiency	Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination: Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered.	American Academy of Neurology
*	N/A/420‡	N/A	Effective Clinical Care		Registry	Outcome	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey: Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.	Society of Interventional Radiology
*	N/A/421‡	N/A	Effective Clinical Care		Registry	Process	Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal: Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.	Society of Interventional Radiology
!	2063/422 ‡	N/A	Patient Safety		Claims, Registry	Process	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury: Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.	American Urogynecologic Society
	0465/423‡	N/A	Effective Clinical Care		Claims, Registry	Process	Perioperative Anti-platelet Therapy for Patients undergoing Carotid Endarterectomy: Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent (aspirin or clopidogrel or equivalent such as aggrenox/tiglacor, etc.) within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery.	Society for Vascular Surgeons
!	2671/424‡	N/A	Patient Safety		Registry	Process	Perioperative Temperature Management: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.	American Society of Anesthesiologists
!	N/A/426‡	N/A	Communication and Care Coordination		Registry	Process	Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU): Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.	American Society of Anesthesiologists
!	N/A/427‡	N/A	Communication and Care Coordination		Registry	Process	Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU): Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member.	American Society of Anesthesiologists
	N/A/428‡	N/A	Effective Clinical Care		Registry	Process	Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence: Percentage of patients undergoing appropriate preoperative evaluation for the indication of stress urinary incontinence per ACOG/AUGS/AUA guidelines.	American Urogynecologic Society
!	N/A/429‡	N/A	Patient Safety		Claims, Registry	Process	Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy: Percentage of patients who are screened for uterine malignancy prior to surgery for pelvic organ prolapse.	American Urogynecologic Society
!	N/A/430‡	N/A	Patient Safety		Registry	Process	Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.	American Society of Anesthesiologists
	2152/431‡	N/A	Community/Population Health		Registry	Process	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user.	American Medical Association-Physician Consortium for Performance Improvement
!	N/A/432‡	N/A	Patient Safety		Registry	Outcome	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery.	American Urogynecologic Society
!	N/A/433‡	N/A	Patient Safety		Registry	Outcome	Proportion of Patients Sustaining a Major Viscus Injury at the Time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscus at the time of index surgery that is recognized intraoperative or within 1 month after surgery.	American Urogynecologic Society
!	N/A/434‡	N/A	Patient Safety		Registry	Outcome	Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery.	American Urogynecologic Society
!	N/A/435‡	N/A	Effective Clinical Care		Claims, Registry	Outcome	Quality Of Life Assessment For Patients With Primary Headache Disorders: Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.	American Academy of Neurology
	N/A/436‡	N/A	Effective Clinical Care		Claims, Registry	Process	Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques: Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	N/A/437‡	N/A	Patient Safety		Claims, Registry	Outcome	Rate of Surgical Conversion from Lower Extremity Endovascular Revasculatization Procedure: Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure.	Society of Interventional Radiology
	N/A/438‡	N/A	Effective Clinical Care		Web Interface, Registry	Process	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease: Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL	Centers for Medicare & Medicaid Services/ Mathematica/Quality Insights of Pennsylvania
§ !!	N/A/439‡	N/A	Efficiency and Cost Reduction		Registry	Efficiency	Age Appropriate Screening Colonoscopy: The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31.	American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
+ !	N/A/New		Communication and Care Coordination		Claims, Registry	Process	Non-melanoma Skin Cancer (NMSC): Biopsy Reporting Time – Pathologist: Length of time taken from when the pathologist completes the final biopsy report to when s/he sends the final report to the biopsying physician. This measure evaluates the reporting time between pathologist and biopsying clinician.	American Academy of Dermatology
+ !	N/A/New		Effective Clinical Care		Registry	Intermediate Outcome	Ischemic Vascular Disease All or None Outcome Measure (Optimal Control): The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use.	Wisconsin Collaborative for Healthcare Quality (WCHQ)
+ §	0071/New		Effective Clinical Care		Registry	Process	Persistent Beta Blocker Treatment After a Heart Attack: The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged alive from 6 months prior to the beginning of the measurement year through the 6 months after the beginning of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge.	National Committee for Quality Assurance
+ § !!	N/A/New		Patient Safety		Registry	Process	Non-recommended Cervical Cancer Screening in Adolescent Females: The percentage of adolescent females 16–20 years of age unnecessarily screened for cervical cancer.	National Committee for Quality Assurance
+ § !	1799/New		Efficiency and Cost Reduction		Registry	Process	Medication Management for People with Asthma (MMA): The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported. 1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period. 2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period.	National Committee for Quality Assurance
+ § !	0119/New		Effective Clinical Care		Registry	Outcome	Risk-Adjusted Operative Mortality for CABG: Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure.	The Society of Thoracic Surgeons
+ § !	0733/New		Patient Safety		Registry	Outcome	Operative Mortality Stratified by the Five STS-EACTS Mortality Categories: Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool.	The Society of Thoracic Surgeons
+ §	1395/New		Community/Population Health		Registry	Process	Chlamydia Screening and Follow-up: The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up.	National Committee for Quality Assurance
+ § !	0567/New		Patient Safety		Registry	Process	Appropriate Work Up Prior to Endometrial Ablation Procedure: To ensure that all women have endometrial sampling performed before undergoing an endometrial ablation	Health Benchmarks – IMS Health
+ § !!	1857/New		Efficiency and Cost Reduction		Registry	Process	Patients with breast cancer and negative or undocumented human epidermal growth factor receptor 2 (HER2) status who are spared treatment with trastuzumab: Percentage of adult patients (aged 18 or over) with invasive breast cancer that is HER2/neu negative who are not administered trastuzumab.	American Society of Clinical Oncology
+ § !!	1858/New		Efficiency and Cost Reduction		Registry	Process	Trastuzumab administered to patients with AJCC stage I (T1c) – III and human epidermal growth factor receptor 2 (HER2) positive breast cancer who receive adjuvant chemotherapy: Percentage of adult patients (aged 18 or over) with invasive breast cancer that is HER2/neu negative who are not administered trastuzumab.	American Society of Clinical Oncology
+ §	1859/New		Effective Clinical Care		Registry	Process	American Society of Clinical Oncology: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed.	American Society of Clinical Oncology
+ § !!	1860/New		Patient Safety		Registry	Process	Patients with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-epidermal growth factor receptor monoclonal antibodies: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies.	American Society of Clinical Oncology
+ § !!	0210/New		Effective Clinical Care		Registry	Process	Proportion receiving chemotherapy in the last 14 days of life: Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.	American Society of Clinical Oncology
+ § !!	0211/New		Effective Clinical Care		Registry	Outcome	Proportion with more than one emergency room visit in the last 30 days of life: Percentage of patients who died from cancer with more than one emergency room visit in the last days of life.	American Society of Clinical Oncology
+ § !!	0213/New		Effective Clinical Care		Registry	Outcome	Proportion admitted to the ICU in the last 30 days of life: Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life.	American Society of Clinical Oncology
+ § !!	0215/New		Effective Clinical Care		Registry	Process	Proportion not admitted to hospice: Percentage of patients who died from cancer not admitted to hospice.	American Society of Clinical Oncology
+ § !!	0216/New		Effective Clinical Care		Registry	Outcome	Proportion admitted to hospice for less than 3 days: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.	American Society of Clinical Oncology

‡ This measure was new to the Physician Quality Reporting System and was adopted for reporting beginning in CY 2016.

¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the timing of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure specifications that apply for each of the reporting options/methods for specific measure details.

TABLE B: Proposed Existing Quality Measures That Are Calculated for 2017 MIPS Performance That Do Not Require Data Submission

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	National Quality Strategy Domain	Measure Type	Measure Title and Description¥	Measure Steward
	N/A	N/A	Communication and Care Coordination	Outcome	Acute Conditions Composite: Bacterial Pneumonia (PQI 11) (NQF 0279) Urinary Tract Infection (PQI 12) (NQF 0281) Dehydration (PQI 10) (NQF 0280)	Agency for Healthcare Research & Quality
	N/A	N/A	Communication and Care Coordination	Outcome	Chronic Conditions Composite: Diabetes (composite of 4 indicators) (PQI 03, 01, 14, 16) (NQF 0274, 0272,0285, 0638) Chronic Obstructive Pulmonary Disease or Asthma (PQI 5) (NQF 0275) Heart Failure (PQI 8) (NQF 0277)	Agency for Healthcare Research & Quality
	1789/N/A	N/A	Communication and Care Coordination	Outcome	All-cause Hospital Readmission Measure: The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge. The measure applies to solo practitioners and groups of practitioners, as identified by their Taxpayer Identification Number (TIN).	Yale University

TABLE C: Proposed Individual Quality Cross-Cutting Measures for the MIPS to Be Available to Meet the Reporting Criteria Via Claims, Registry, and EHR Beginning in 2017

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	National Quality Strategy Domain	Data Submission Method	Measure Type	Measure Title and Description¥	Measure Steward
!	0326/047	N/A	Communication and Care Coordination	Claims, Registry	Process	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.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
* !	0419/130	68v5	Patient Safety	Claims, Registry, EHR	Process	Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
§	0028/226	138v4	Community/ Population Health	Claims, Web Interface, Registry, EHR	Process	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.	American Medical Association-Physician Consortium for Performance Improvement
§ !	0018/236	165v4	Effective Clinical Care	Claims, Web Interface, Registry, EHR	Intermediate Outcome	Controlling: High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.	National Committee for Quality Assurance
*	N/A/ 317	22v4	Community/ Population Health	Claims, Registry, EHR	Process	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	N/A/ 374	50v4	Communication and Care Coordination	EHR	Process	Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.	Centers for Medicare & Medicaid Services/ Mathematica
	N/A/ 402	N/A	Community/ Population Health	Registry	Process	Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.	National Committee for Quality Assurance/ National Collaborative for Innovation in Quality Measurement
	2152/431	N/A	Community/ Population Health	Registry	Process	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user	American Medical Association-Physician Consortium for Performance Improvement
* §	0421/128	69v4	Community/Population Health	Claims, Web Interface, Registry, EHR	Process	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 18 – 64 years BMI ≥ 18.5 and < 25 kg/m2.	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
§ !	0005 & 0006/321	N/A	Person and Caregiver-Centered Experience and Outcomes	CMS-approved Survey Vendor	Patient Engagement/Experience	CAHPS for MIPS Clinician/Group Survey: Summary Survey Measures may include: • Getting Timely Care, Appointments, and Information; • How well Providers Communicate; • Patient’s Rating of Provider; • Access to Specialists; • Health Promotion and Education; • Shared Decision-Making; • Health Status and Functional Status; • Courteous and Helpful Office Staff; • Care Coordination; • Between Visit Communication; • Helping You to Take Medication as Directed; and • Stewardship of Patient Resources.	Agency for Healthcare Research & Quality

TABLE D: Proposed New Measures for MIPS Reporting in 2017

Title	Non-melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Pathologist
NQF #:	N/A
Description:	Length of time taken from when the pathologist completes the final biopsy report to when s/he sends the final report to the biopsying physician. This measure evaluates the reporting time between pathologist and biopsying clinician
Measure Steward:	American Academy of Dermatology
Numerator:	Number of final pathology reports diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 5 business days from the time when the tissue specimen was received by the pathologist
Denominator:	All pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease)
Exclusions:	Pathologists/Dermatopathologists providing a second opinion on a biopsy
Measure Type:	Process
Measure Domain:	Communication and Care Coordination
Data Submission Method:	Claims, Registry
Rationale:	CMS proposes the NMSC measure to address a clinical performance gap of communication between pathologists and clinicians regarding final biopsy reports. CMS believes this measure is relevant for pathologists which is a specialty that does not have many relevant measures they can report. During the Measures Application Partnership (MAP) review, the MAP supports this measure and encourages further development.
Title	Ischemic Vascular Disease All or None Outcome Measure (Optimal Control)
NQF #:	N/A
Description:	The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use
Measure Steward:	Wisconsin Collaborative for Healthcare Quality (WCHQ)
Numerator:	Most recent BP is less than 140/90 mm Hg And Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure) And Daily Aspirin or Other Antiplatelet Unless Contraindicated And Statin Use
Denominator:	Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the Measurement Period. A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months
Exclusions:	History of Gastrointestinal Bleed or Intra-cranial Bleed or documentation of active anticoagulant use during the MP for the Aspirin/Other Anticoagulant component (numerator) of the measure. Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) for the Blood Pressure Control component (numerator) of the composite measure
Measure Type:	Intermediate Outcome
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS proposes the All or None (Composite) measure because it provides benefits to both the patient and the practitioner. CMS believes this measure closely reflects the interests and likely desires of the patient which is a high priority of CMS. Secondly, this measure is an outcome measure that represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. During the Measures Application Partnership (MAP) review, the MAP conditionally supports this measure for implementation in 2017. However, the MAP would like to see a future measure that includes patient compliance as part of the composite.
Title	Persistent Beta Blocker Treatment After a Heart Attack
NQF #:	0071
Description:	The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged alive from 6 months prior to the beginning of the measurement year through the 6 months after the beginning of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge
Measure Steward:	National Committee for Quality Assurance
Numerator:	Patients who had a 180-day course of treatment with beta-blockers post discharge
Denominator:	Patients 18 years of age and older by the end of the measurement year who were discharged alive from an acute inpatient setting with an AMI from 6 months prior to the beginning of the measurement year through the 6 months after the beginning of the measurement year
Exclusions:	Exclude patients who are identified as having an intolerance or allergy to beta-blocker therapy. Look as far back as possible in the patient’s history for evidence of a contraindication to beta-blocker therapy Exclude from the denominator hospitalizations in which the patient was transferred directly to a non-acute care facility for any diagnosis
Measure Type:	Process
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address cardiovascular care. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Non-recommended Cervical Cancer Screening in Adolescent Females
NQF #:	N/A
Description:	The percentage of adolescent females 16–20 years of age unnecessarily screened for cervical cancer
Measure Steward:	National Committee for Quality Assurance
Numerator:	Cervical cytology (Cervical Cytology Value Set) or an HPV test (HPV Tests Value Set) performed during the measurement year
Denominator:	Adolescent females 16-20 years as of December 31 of the measurement year
Exclusions:	A history of cervical cancer (Cervical Cancer Value Set), HIV (HIV Value Set) or immunodeficiency (Disorders of the Immune System Value Set) any time during the member’s history through December 31 of the measurement year
Measure Type:	Process
Measure Domain:	Patient Safety
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address care coordination and patient safety within primary care. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Medication Management for People with Asthma (MMA)
NQF #:	1799
Description:	The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported 1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period 2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period
Measure Steward:	National Committee for Quality Assurance
Numerator:	Medication Compliance 50%: The number of patients who achieved a PDC* of at least 50% for their asthma controller medications during the measurement year Medication Compliance 75%: The number of patients who achieved a PDC* of at least 75% for their asthma controller medications during the measurement year *PDC is the proportion of days covered by at least one asthma controller medication prescription, divided by the number of days in the treatment period
Denominator:	Patients 5–64 years of age during the measurement year who were identified as having persistent asthma
Exclusions:	1) Exclude patients who had any diagnosis of Emphysema (Emphysema Value Set, Other Emphysema Value Set), COPD (COPD Value Set), Chronic Bronchitis (Obstructive Chronic Bronchitis Value Set, Chronic Respiratory Conditions Due To Fumes/Vapors Value Set), Cystic Fibrosis (Cystic Fibrosis Value Set) or Acute Respiratory Failure (Acute Respiratory Failure Value Set) any time during the patient’s history through the end of the measurement year (e.g., December 31) 2) Exclude any patients who have no asthma controller medications (Table ASM-D) dispensed during the measurement year
Measure Type:	Process
Measure Domain:	Efficiency and Cost Reduction
Data Submission Method	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address pulmonary care within primary care. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Risk-Adjusted Operative Mortality for CABG
NQF #:	0119
Description:	Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Measure Steward:	The Society of Thoracic Surgeons
Numerator:	Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Denominator:	All patients undergoing isolated CABG
Exclusions:	N/A
Measure Type:	Outcome
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address chronic cardiovascular condition. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Operative Mortality Stratified by the Five STS-EACTS Mortality Categories
NQF #:	0733
Description:	Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool
Measure Steward:	The Society of Thoracic Surgeons
Numerator:	Number of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool
Denominator:	All patients undergoing index pediatric and/or congenital heart surgery
Exclusions:	N/A
Measure Type:	Outcome
Measure Domain:	Patient Safety
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address pediatric heart surgery. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Chlamydia Screening and Follow-up
NQF #:	1395
Description:	The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up
Measure Steward:	National Committee for Quality Assurance
Numerator:	Adolescents who had documentation of a chlamydia screening test with proper follow-up by the time they turn 18 years of age
Denominator:	Sexually active female adolescents with a visit who turned 18 years of age during the measurement year
Exclusions:	N/A
Measure Type:	Process
Measure Domain:	Community/Population Health
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address obstetrics and gynecology conditions. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Appropriate Work Up Prior to Endometrial Ablation Procedure
NQF #:	0567
Description:	To ensure that all women have endometrial sampling performed before undergoing an endometrial ablation
Measure Steward:	Health Benchmarks – IMS Health
Numerator:	Women who received endometrial sampling or hysteroscopy with biopsy during the year prior to the index date (inclusive of the index date)
Denominator:	Continuously enrolled women who had an endometrial ablation procedure during the measurement year
Exclusions:	Women who had an endometrial ablation procedure during the year prior to the index date (exclusive of the index date)
Measure Type:	Process
Measure Domain:	Patient Safety
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address obstetrics and gynecology conditions. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	1857 - Patients with breast cancer and negative or undocumented human epidermal growth factor receptor 2 (HER2) status who are spared treatment with trastuzumab
NQF #:	1857
Description:	Percentage of adult patients (aged 18 or over) with invasive breast cancer that is HER2/neu negative who are not administered trastuzumab
Measure Steward:	American Society of Clinical Oncology
Numerator:	Trastuzumab not administered during the initial course of treatment
Denominator:	Adult women with AJCC stage I (T1c) – III breast cancer that is HER-2 negative or HER-2 undocumented/unknown
Exclusions:	Patient transfer to practice after initiation of chemotherapy
Measure Type:	Process
Measure Domain:	Efficiency and Cost Reduction
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Trastuzumab administered to patients with AJCC stage I (T1c) – III and human epidermal growth factor receptor 2 (HER2) positive breast cancer who receive adjuvant chemotherapy
NQF #:	1858
Description:	Percentage of adult patients (aged 18 or over) with invasive breast cancer that is HER2/neu negative who are not administered trastuzumab
Measure Steward:	American Society of Clinical Oncology
Numerator:	Trastuzumab not administered during the initial course of treatment
Denominator:	Adult women with AJCC stage I (T1c) – III breast cancer that is HER-2 negative or HER-2 undocumented/unknown
Exclusions:	Patient transfer to practice after initiation of chemotherapy
Measure Type:	Process
Measure Domain:	Efficiency and Cost Reduction
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	KRAS gene mutation testing performed for patients with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy
NQF #:	1859
Description:	Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed
Measure Steward:	American Society of Clinical Oncology
Numerator:	KRAS gene mutation testing performed before initiation of anti-EGFR MoAb
Denominator:	Adult patients with metastatic colorectal cancer who receive anti-EGFR monoclonal antibody therapy
Exclusions:	Patient transfer to practice after initiation of chemotherapy
Measure Type:	Process
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Patients with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-epidermal growth factor receptor monoclonal antibodies
NQF #:	1860
Description:	Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies
Measure Steward:	American Society of Clinical Oncology
Numerator:	Anti-EGFR monoclonal antibody therapy not received
Denominator:	Adult patients with metastatic colorectal cancer who have a KRAS gene mutation
Exclusions:	Patient transfer to practice after initiation of chemotherapy Receipt of anti-EGFR monoclonal antibody therapy as part of a clinical trial protocol
Measure Type:	Process
Measure Domain:	Patient Safety
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Proportion receiving chemotherapy in the last 14 days of life
NQF #:	0210
Description:	Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life
Measure Steward:	American Society of Clinical Oncology
Numerator:	Patients who died from cancer and received chemotherapy in the last 14 days of life
Denominator:	Patients who died from cancer
Exclusions:	N/A
Measure Type:	Process
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Proportion with more than one emergency room visit in the last 30 days of life
NQF #:	0211
Description:	Percentage of patients who died from cancer with more than one emergency room visit in the last days of life
Measure Steward:	American Society of Clinical Oncology
Numerator:	Patients who died from cancer and had >1 ER visit in the last 30 days of life
Denominator:	Patients who died from cancer
Exclusions:	N/A
Measure Type:	Outcome
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Proportion admitted to the ICU in the last 30 days of life
NQF #:	0213
Description:	Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life
Measure Steward:	American Society of Clinical Oncology
Numerator:	Patients who died from cancer and were admitted to the ICU in the last 30 days of life
Denominator:	Patients who died from cancer
Exclusions:	N/A
Measure Type:	Outcome
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Proportion not admitted to hospice
NQF #:	0215
Description:	Percentage of patients who died from cancer not admitted to hospice
Measure Steward:	American Society of Clinical Oncology
Numerator:	Patients who died from cancer without being admitted to hospice
Denominator:	Patients who died from cancer
Exclusions:	N/A
Process Type:	Process
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).
Title	Proportion admitted to hospice for less than 3 days
NQF #:	0216
Description:	Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there
Measure Steward:	American Society of Clinical Oncology
Numerator:	Patients who died from cancer and spent fewer than three days in hospice
Denominator:	Patients who died from cancer who were admitted to hospice
Exclusions:	N/A
Measure Type:	Outcome
Measure Domain:	Effective Clinical Care
Data Submission Method:	Registry
Rationale:	CMS, as part of the core measure collaborative, proposes this measure to fulfill a set of condition-specific core measures. CMS believes the core measure collaborative fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is proposed as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to propose measures that were not reviewed by the Measures Application Partnership (MAP).

TABLE E: 2017 Proposed MIPS Specialty Measure Sets

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Allergy/Immunology/Rheumatology
	0041/110	147v5	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Preventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization	American Medical Association-Physician Consortium for Performance Improvement
	0043/111	127v4	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Pneumonia Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine	National Committee for Quality Assurance
* §	0405/160	52v4	EHR	Process	Effective Clinical Care	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis	National Committee for Quality Assurance
*	N/A/ 176	N/A	Registry	Process	Effective Clinical Care	Rheumatoid Arthritis (RA): Tuberculosis Screening Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)	American College of Rheumatology
*	N/A/ 177	N/A	Registry	Process	Effective Clinical Care	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months	American College of Rheumatology
	N/A/ 178	N/A	Registry, Measures Group	Process	Effective Clinical Care	Rheumatoid Arthritis (RA): Functional Status Assessment Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months	American College of Rheumatology
*	N/A/ 179	N/A	Registry	Process	Effective Clinical Care	Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months	American College of Rheumatology
*	N/A/ 180	N/A	Registry	Process	Effective Clinical Care	Rheumatoid Arthritis (RA): Glucocorticoid Management Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months	American College of Rheumatology
!!	N/A/331	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 332	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 333	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 334	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
	N/A/ 337	N/A	Registry	Process	Effective Clinical Care	Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test	American Academy of Dermatology
!	N/A/ 398	N/A	Registry	Process	Efficiency and Cost Reduction	Optimal Asthma Control Patients ages 5-50 (pediatrics ages 5-17) whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools	Minnesota Community Measurement
+ § !	1799/ NA	NA	Registry	Process	Efficiency and Cost Reduction	Medication Management for People with Asthma (MMA): The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported. 1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period. 2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period.	National Committee for Quality Assurance
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered a patient-facing provider, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Anesthesiology
!	N/A/ 076	N/A	Claims, Registry	Process	Patient Safety	Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed	American Society of Anesthesiologists
!	N/A/ 404	N/A	Registry	Intermediate Outcome	Effective Clinical Care	Anesthesiology Smoking Abstinence The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.	American Society of Anesthesiologists
!	2681/424	N/A	Registry	Process	Patient Safety	Perioperative Temperature Management Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time	American Society of Anesthesiologists
!	N/A/ 426	N/A	Registry	Process	Communication and Care Coordination	Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized	American Society of Anesthesiologists
!	N/A/ 427	N/A	Registry	Process	Communication and Care Coordination	Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member	American Society of Anesthesiologists
!	N/A/ 430	N/A	Registry	Process	Patient Safety	Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively	American Society of Anesthesiologists
	0236/044	N/A	Registry	Process	Effective Clinical Care	Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Cardiology
§	0081/005	135v4	Registry, EHR	Process	Effective Clinical Care	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* §	0083/008	144v4	Registry, EHR	Process	Effective Clinical Care	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* §	0066/118	N/A	Registry	Process	Effective Clinical Care	Chronic Stable Coronary Artery Disease: ACE Inhibitor or ARB Therapy--Diabetes or Left Ventricular Systolic Dysfunction (LVEF <40%) Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
* §	0067/006	N/A	Registry	Process	Effective Clinical Care	Chronic Stable Coronary Artery Disease: Antiplatelet Therapy Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
§	0070/007	145v4	Registry, EHR	Process	Effective Clinical Care	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	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
§	1525/326	N/A	Claims, Registry	Process	Effective Clinical Care	Chronic Anticoagulation Therapy Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance
	N/A/438	N/A	Web Interface, Registry	Process	Effective Clinical Care	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL	Centers for Medicare & Medicaid Services/ Mathematica/Quality Insights of Pennsylvania
§	0070/007	145v4	Registry, EHR	Process	Effective Clinical Care	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	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
* §	0068/204	164v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.	National Committee for Quality Assurance
!!	N/A/ 322	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period	American College of Cardiology
!!	N/A/ 323	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status	American College of Cardiology
!!	N/A/ 324	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment	American College of Cardiology
3a. Electrophysiology Cardiac Specialist
!	N/A/ 348	N/A	Registry	Outcome	Patient Safety	HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD	The Heart Rhythm Society
!	2474/392	N/A	Registry	Outcome	Patient Safety	HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender: • Reporting Age Criteria 1: Females less than 65 years of age • Reporting Age Criteria 2: Males less than 65 years of age • Reporting Age Criteria 3: Females 65 years of age and older • Reporting Age Criteria 4: Males 65 years of age and older	The Heart Rhythm Society
!	N/A/ 393	N/A	Registry	Outcome	Patient Safety	HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Infection rate following CIED device implantation, replacement, or revision	The Heart Rhythm Society
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number		NQF/ PQRS		CMS E-Measure ID		Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥		Measure Steward
Gastroenterology
§	0034/113		130v4		Claims, Web Interface, Registry, EHR		Process	Effective Clinical Care	Colorectal Cancer Screening Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer	National Committee for Quality Assurance
§ !!	0659/185		N/A		Claims, Registry		Process	Communication and Care Coordination	Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy	American Medical Association-Physician Consortium for Performance Improvement American / Gastroenterological Association/ 'American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
§ !!	0658/320		N/A		Claims, Registry		Process	Communication and Care Coordination	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report	American Medical Association-Physician Consortium for Performance Improvement / American Gastroenterological Association/ 'American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
§ !	N/A/ 343		N/A		Registry		Outcome	Effective Clinical Care	Screening Colonoscopy Adenoma Detection Rate Measure The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy	American College of Gastroenterology / American Gastroenterological Association/ 'American Society for Gastrointestinal Endoscopy
!	N/A/ 390		N/A		Registry		Process	Person and Caregiver-Centered Experience and Outcomes	Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
§	N/A/401		N/A		Registry		Process	Effective Clinical Care	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
§ !!	N/A/ 439		N/A		Registry		Efficiency	Efficiency and Cost Reduction	Age Appropriate Screening Colonoscopy The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31	American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Dermatology
!	0650/ 137	N/A	Registry	Structure	Communication and Care Coordination	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	American Academy of Dermatology/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 138	N/A	Registry	Process	Communication and Care Coordination	Melanoma: Coordination of Care Percentage of patients visits, regardless of age, with a new occurrence of melanoma, who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis	American Academy of Dermatology/ American Medical Association-Physician Consortium for Performance Improvement
!!	0562/ 224	N/A	Registry	Process	Efficiency and Cost Reduction	Melanoma: Overutilization of Imaging Studies in Melanoma Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.	American Academy of Dermatology/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 265	N/A	Registry	Process	Communication and Care Coordination	Biopsy Follow-Up Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician	American Academy of Dermatology
	N/A/ 337	N/A	Registry	Process	Effective Clinical Care	Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test	American Academy of Dermatology
!	N/A/ 410		Claims, Registry	Outcome	Person and Caregiver Centered Experience and Outcomes	Psoriasis: Clinical Response to Oral Systemic or Biologic Medications Percentage of psoriasis patients receiving oral systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.	American Academy of Dermatology
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Emergency Medicine
* !!	N/A/ 066	146v4	Registry, EHR	Process	Efficiency and Cost Reduction	Appropriate Testing for Children with Pharyngitis Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode	National Committee for Quality Assurance
!!	0653/ 091	N/A	Claims, Registry	Process	Effective Clinical Care	Acute Otitis Externa (AOE): Topical Therapy Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations	American Academy of Otolaryngology-Head and Neck Surgery
!!	0654/ 093	N/A	Claims, Registry	Process	Efficiency and Cost Reduction	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	American Academy of Otolaryngology-Head and Neck Surgery
§ !!	0058/ 116	N/A	Registry	Process	Efficiency and Cost Reduction	Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode	National Committee for Quality Assurance
	0651/ 254	N/A	Claims, Registry	Process	Effective Clinical Care	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	American College of Emergency Physicians
	N/A/ 255	N/A	Claims, Registry	Process	Effective Clinical Care	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)	American College of Emergency Physicians
	N/A/ 414	N/A	Registry	Process	Effective Clinical Care	Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record	American Academy of Neurology
!	N/A/ 415	N/A	Claims, Registry	Efficiency	Efficiency and Cost Reduction	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.	American College of Emergency Physicians
!!	N/A/ 416	N/A	Claims, Registry	Efficiency	Efficiency and Cost Reduction	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network prediction rules for traumatic brain injury	American College of Emergency Physicians
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
General Practice/Family Medicine
* § !	0059/001	122v4	Claims, Registry, EHR	Intermediate Outcome	Effective Clinical Care	Diabetes: Hemoglobin A1c Poor Control Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period	National Committee for Quality Assurance
§	0081/005	135v4	Registry, EHR	Process	Effective Clinical Care	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge	American Medical Association-Physician Consortium for Performance/American College of Cardiology Foundation/American Heart Association
	105/ 009	128v4	EHR	Process	Effective Clinical Care	Anti-Depressant Medication Management Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)	National Committee for Quality Assurance/American Heart Association
!	N/A/ 050	N/A	Claims, Registry	Process	Person and Caregiver-Centered Experience and Outcomes	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	National Committee for Quality Assurance/American Medical Association-Physician Consortium for Performance Improvement
!!	0069/065	154v4	Registry, EHR	Process	Efficiency and Cost Reduction	Appropriate Treatment for Children with Upper Respiratory Infection (URI) Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode	National Committee for Quality Assurance
* !!	N/A/066	146v4	Registry, EHR	Process	Efficiency and Cost Reduction	Appropriate Testing for Children with Pharyngitis Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode	National Committee for Quality Assurance
!!	0654/093	N/A	Claims, Registry	Process	Efficiency and Cost Reduction	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	American Academy of Otolaryngology-Head and Neck Surgery
!	N/A/ 109	N/A	Claims, Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain	American Academy of Orthopedic Surgeons
* §	2372/112	125v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Breast Cancer Screening Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer	National Committee for Quality Assurance
§	0034/113	130v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Colorectal Cancer Screening Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer	National Committee for Quality Assurance
§ !!	0058/116	N/A	Registry	Process	Efficiency and Cost Reduction	Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode	National Committee for Quality Assurance
§	0055/117	131v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Diabetes: Eye Exam Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period	National Committee for Quality Assurance
*	0418/134	2v5	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Preventive Care and Screening: Screening for Depression and Follow-Up Plan Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	0101/154	N/A	Claims, Registry	Process	Patient Safety	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	0101/155	N/A	Claims, Registry	Process	Communication and Care Coordination	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	National Committee for Quality Assurance/ 'American Medical Association-Physician Consortium for Performance Improvement
!	NA/ 181	N/A	Claims, Registry	Process	Patient Safety	Elder Maltreatment Screen and Follow-Up Plan Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
* §	0068/204	164v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period	National Committee for Quality Assurance
§ !!	0052/312	166v5	Web Interface, EHR	Process	Efficiency and Cost Reduction	Use of Imaging Studies for Low Back Pain Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis	National Committee for Quality Assurance
§	1525/326	N/A	Claims, Registry	Process	Effective Clinical Care	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
!!	N/A/ 331	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 332	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 333	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 334	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
	N/A/ 337	N/A	Registry	Process	Effective Clinical Care	Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test	American Academy of Dermatology
* § !	2082/338	N/A	Registry	Outcome	Effective Clinical Care	HIV Viral Load Suppression The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year	Health Resources and Services Administration
!	N/A/ 342	N/A	Registry	Outcome	Person and Caregiver-Centered Experience and Outcomes	Pain Brought Under Control Within 48 Hours Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours	National Hospice and Palliative Care Organization
	N/A/ 387	N/A	Registry	Process	Effective Clinical Care	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period	American Medical Association-Physician Consortium for Performance Improvement
	1407/394	N/A	Registry	Process	Community/ Population Health	Immunizations for Adolescents The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday	National Committee for Quality Assurance
!	N/A/ 398	N/A	Registry	Outcome	Effective Clinical Care	Optimal Asthma Control Patients ages 5-50 (pediatrics ages 5-17) whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools	Minnesota Community Measurement
§	N/A/ 400	N/A	Registry	Process	Effective Clinical Care	One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received a one-time screening for HCV infection	American Medical Association-Physician Consortium for Performance Improvement
§	N/A/401	N/A	Registry	Process	Effective Clinical Care	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
	N/A/ 408	N/A	Registry	Process	Effective Clinical Care	Opioid Therapy Follow-up Evaluation All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 412	N/A	Registry	Process	Effective Clinical Care	Documentation of Signed Opioid Treatment Agreement All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 414	N/A	Registry	Process	Effective Clinical Care	Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record	American Academy of Neurology
	0053/418	N/A	Claims, Registry	Process	Effective Clinical Care	Osteoporosis Management in Women Who Had a Fracture The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
	N/A/438	N/A	Web Interface, Registry	Process	Effective Clinical Care	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL	Centers for Medicare & Medicaid Services/ Mathematica/Quality Insights of Pennsylvania
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Internal Medicine
* § !	0059/001	122v4	Claims, Web Interface, Registry, EHR	Intermediate Outcome	Effective Clinical Care	Diabetes: Hemoglobin A1c Poor Control Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period	National Committee for Quality Assurance
§	0081/005	135v4	Registry, EHR	Process	Effective Clinical Care	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge	American Medical Association-Physician Consortium for Performance Improvement/American College of Cardiology Foundation
	105/ 009	128v4	EHR	Process	Effective Clinical Care	Anti-Depressant Medication Management Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)	National Committee for Quality Assurance/American Heart Association
!	N/A/ 050	N/A	Claims, Registry	Process	Person and Caregiver Centered Experience and Outcomes	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	National Committee for Quality Assurance/American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 109	N/A	Claims, Registry	Process	Person and Caregiver Centered Experience and Outcomes	Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain	American Academy of Orthopedic Surgeons
* §	2372/112	125v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Breast Cancer Screening Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer	National Committee for Quality Assurance
§	0034/113	130v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Colorectal Cancer Screening Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer	National Committee for Quality Assurance
§ !!	0058/116	N/A	Registry	Process	Efficiency and Cost Reduction	Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use Percentage of adults 18 through 64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or 3 days after the episode	National Committee for Quality Assurance
§	0055/117	131v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Diabetes: Eye Exam Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period	National Committee for Quality Assurance
*	0418/134	2v5	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Preventive Care and Screening: Screening for Depression and Follow-Up Plan Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	0101/154	N/A	Claims, Registry	Process	Patient Safety	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	0101/155	N/A	Claims, Registry	Process	Communication and Care Coordination	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
* §	0056/163	123v4	EHR	Process	Effective Clinical Care	Comprehensive Diabetes Care: Foot Exam The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year	National Committee for Quality Assurance
!	N/A/ 181	N/A	Claims, Registry	Process	Patient Safety	Elder Maltreatment Screen and Follow-Up Plan Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
* §	0068/204	164v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period	National Committee for Quality Assurance
§	1525/326	N/A	Claims, Registry	Process	Effective Clinical Care	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
!!	N/A/ 331	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 332	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 333	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 334	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
	N/A/ 387	N/A	Registry	Process	Effective Clinical Care	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period	American Medical Association-Physician Consortium for Performance Improvement
§	N/A/ 400	N/A	Registry	Process	Effective Clinical Care	One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received a one-time screening for HCV infection	American Medical Association-Physician Consortium for Performance Improvement
§	N/A/401	N/A	Registry	Process	Effective Clinical Care	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period This measure was finalized for inclusion in 2015 PQRS in the CY 2014 PFS Final Rule (see Table 53 at 79 FR 67814)	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
	N/A/ 408	N/A	Registry	Process	Effective Clinical Care	Opioid Therapy Follow-up Evaluation All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 412	N/A	Registry	Process	Effective Clinical Care	Documentation of Signed Opioid Treatment Agreement All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 414	N/A	Registry	Process	Effective Clinical Care	Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record	American Academy of Neurology
	0053/418	N/A	Claims, Registry	Process	Effective Clinical Care	Osteoporosis Management in Women Who Had a Fracture The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Obstetrics/Gynecology
	N/A/ 048	N/A	Claims, Registry	Process	Effective Clinical Care	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 050	N/A	Claims, Registry	Process	Person and Caregiver-Centered Experience and Outcomes	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 265	N/A	Registry	Process	Communication and Care Coordination	Biopsy Follow-Up Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician	American Academy of Dermatology
	0053/418	N/A	Claims, Registry	Process	Effective Clinical Care	Osteoporosis Management in Women Who Had a Fracture The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	2063/422	N/A	Claims, Registry	Process	Patient Safety	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse	American Urogynecologic Society
!	N/A/ 432	N/A	Registry	Outcome	Patient Safety	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery	American Urogynecologic Society
!	N/A/ 433	N/A	Registry	Outcome	Patient Safety	Proportion of Patients Sustaining a Major Viscus Injury at the Time of Any Pelvic Organ Prolapse Repair Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by perforation of a major viscus at the time of index surgery that is recognized intraoperative or within 1 month after surgery	American Urogynecologic Society
!	N/A/ 434	N/A	Registry	Outcome	Patient Safety	Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair Percentage of patients undergoing a pelvic organ prolapse repair who sustain an injury to the ureter recognized either during or within 1 month after surgery	American Urogynecologic Society
* §	0032/309	124v4	EHR	Process	Effective Clinical Care	Cervical Cancer Screening Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria: • Women age 21–64 who had cervical cytology performed every 3 years • Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years	National Committee for Quality Assurance
+ §	1395/ New	N/A	Registry	Process	Community/ Population Health	Chlamydia Screening and Follow-up The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up	National Committee for Quality Assurance
* §	2372/112	125v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Breast Cancer Screening Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer	National Committee for Quality Assurance
+ § !	0567/ New	N/A	Registry	Process	Patient Safety	Appropriate Work Up Prior to Endometrial Ablation Procedure To ensure that all women have endometrial sampling performed before undergoing an endometrial ablation	Health Benchmarks-IMS Health
+ § !!	N/A/New	N/A	Registry	Process	Patient Safety	Non-recommended Cervical Cancer Screening in Adolescent Females The percentage of adolescent females 16–20 years of age unnecessarily screened for cervical cancer	National Committee for Quality Assurance
	0033/310	153v4	EHR	Process	Community/ Population Health	Chlamydia Screening for Women Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period	National Committee for Quality Assurance
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Ophthalmology
	0086/012	143v4	Claims, Registry, EHR	Process	Effective Clinical Care	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
	0087/014	N/A	Claims, Registry	Process	Effective Clinical Care	Age-Related Macular Degeneration (AMD): Dilated Macular Examination Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months	American Academy of Ophthalmology
	0088/018	167v4	EHR	Process	Effective Clinical Care	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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0089/019	142v4	Claims, Registry, EHR	Process	Communication and Care Coordination	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
§	0055/117	131v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Diabetes: Eye Exam Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period	National Committee for Quality Assurance
	0566/140	N/A	Claims, Registry	Process	Effective Clinical Care	Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD	American Academy of Ophthalmology
!	0563/141	N/A	Claims, Registry	Outcome	Communication and Care Coordination	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months	American Academy of Ophthalmology
!	0565/191	133v4	Registry, EHR	Outcome	Effective Clinical Care	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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0564/192	132v4	Registry, EHR	Outcome	Patient Safety	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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	1536/303	N/A	Registry	Outcome	Person Caregiver-Centered Experience and Outcomes	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	American Academy of Ophthalmology
!	N/A/304	N/A	Registry	Outcome	Person Caregiver-Centered Experience and Outcomes	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	American Academy of Ophthalmology
!	N/A/384	N/A	Registry	Outcome	Effective Clinical Care	Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.	American Academy of Ophthalmology
!	N/A/ 385	N/A	Registry	Outcome	Effective Clinical Care	Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye	American Academy of Ophthalmology/ The Australian Council on Healthcare Standards
!	N/A/ 388	N/A	Registry	Outcome	Patient Safety	Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy	American Academy of Ophthalmology/ American College of Healthcare Sciences
!	N/A/ 389	N/A	Registry	Outcome	Effective Clinical Care	Cataract Surgery: Difference Between Planned and Final Refraction Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.	American Academy of Ophthalmology/ American College of Healthcare Sciences
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type		National Quality Strategy Domain		Measure Title and Description¥	Measure Steward
Orthopedic Surgery
!!	0268/021	N/A	Claims, Registry		Process		Patient Safety	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0239/ 023	N/A	Claims, Registry		Process		Patient Safety	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical 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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	N/A/ 109	N/A	Claims, Registry		Process		Person and Caregiver-Centered Experience and Outcomes	Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain	American Academy of Orthopedic Surgeons
	N/A/ 178	N/A	Registry, Measures Group		Process		Effective Clinical Care	Rheumatoid Arthritis (RA): Functional Status Assessment Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months	American College of Rheumatology
*	N/A/ 179	N/A	Registry		Process		Effective Clinical Care	Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months	American College of Rheumatology
*	N/A/ 180	N/A	Registry		Process		Effective Clinical Care	Rheumatoid Arthritis (RA): Glucocorticoid Management Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months	American College of Rheumatology
§ !!	0052/312	166v5	Web Interface, EHR		Process		Efficiency and Cost Reduction	Use of Imaging Studies for Low Back Pain Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis	National Committee for Quality Assurance
* !	N/A/ 350	N/A	Registry		Process		Communication and Care Coordination	Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Percentage of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure	American Association of Hip and Knee Surgeons
* !	N/A/ 351	N/A	Registry		Process		Patient Safety	Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)	American Association of Hip and Knee Surgeons
* !	N/A/ 352	N/A	Registry		Process		Patient Safety	Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet	American Association of Hip and Knee Surgeons
* !	N/A/ 353	N/A	Registry		Process		Patient Safety	Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report Percentage of patients regardless of age or gender undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant	American Association of Hip and Knee Surgeons
!	N/A/ 358	N/A	Registry, Measures Group		Process		Person and Caregiver-Centered Experience and Outcomes	Patient-Centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon	American Association of Hip and Knee Surgeons
* !	N/A/ 375	N/A	Measures Group		Process		Person and Caregiver-Centered Experience and Outcomes	Functional Status Assessment for Total Knee Replacement Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments	Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
* !	N/A/ 376	N/A	EHR		Process		Person and Caregiver-Centered Experience and Outcomes	Functional Status Assessment for Total Hip Replacement Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments	Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Otolaryngology
!!	0268/ 021	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0239/023	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical 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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!!	0653/ 091	N/A	Claims, Registry	Process	Effective Clinical Care	Acute Otitis Externa (AOE): Topical Therapy Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations	'American Academy of Otolaryngology-Head and Neck Surgery
!!	0654/ 093	N/A	Claims, Registry	Process	Efficiency and Cost Reduction	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	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 331	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 332	N/A	Registry	Process	Efficiency and Cost Reduction	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 333	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
!!	N/A/ 334	N/A	Registry	Efficiency	Efficiency and Cost Reduction	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis	American Academy of Otolaryngology-Head and Neck Surgery
* !	N/A/ 357	N/A	Registry	Outcome	Effective Clinical Care	Surgical Site Infection (SSI) Percentage of patients aged 18 years and older who had a surgical site infection (SSI)	American College of Surgeons
!	N/A/ 358	N/A	Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Patient-Centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon	American College of Surgeons
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Pathology
	0391/099	N/A	Claims, Registry	Process	Effective Clinical Care	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	College of American Pathologists
	0392/100	N/A	Claims, Registry	Process	Effective Clinical Care	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	College of American Pathologists
	1854/249	N/A	Claims, Registry	Structure	Effective Clinical Care	Barrett's Esophagus Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia	College of American Pathologists
§	1853/250	N/A	Claims, Registry	Structure	Effective Clinical Care	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	College of American Pathologists
	1855/251	N/A	Claims, Registry	Structure	Effective Clinical Care	Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer	College of American Pathologists
!	N/A/ 395	N/A	Claims, Registry	Process	Communication and Care Coordination	Lung Cancer Reporting (Biopsy/Cytology Specimens) Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary nonsmall cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report	College of American Pathologists
!	N/A/ 396	N/A	Claims, Registry	Process	Communication and Care Coordination	Lung Cancer Reporting (Resection Specimens) Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type	College of American Pathologists
!	N/A/ 397	N/A	Claims, Registry	Process	Communication and Care Coordination	Melanoma Reporting Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate	College of American Pathologists
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Pediatrics
!!	0069/065	154v4	Registry, EHR	Process	Efficiency and Cost Reduction	Appropriate Treatment for Children with Upper Respiratory Infection (URI) Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.	National Committee for Quality Assurance
* !!	N/A/ 066	146v4	Registry, EHR	Process	Efficiency and Cost Reduction	Appropriate Testing for Children with Pharyngitis Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.	National Committee for Quality Assurance
!!	0653/091	N/A	Claims, Registry	Process	Effective Clinical Care	Acute Otitis External (AOE): Topical Therapy Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations	American Academy of Otolaryngology-Head and Neck Surgery
!!	0654/ 093	N/A	Claims, Registry	Process	Efficiency and Cost Reduction	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	American Academy of Otolaryngology-Head and Neck Surgery
	0041/110	147v5	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Preventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization	American Medical Association-Physician Consortium for Performance Improvement
*	0418/134	2v5	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Preventive Care and Screening: Screening for Depression and Follow-Up Plan Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen	Centers for Medicare & Medicaid Services/ 'Mathematica/ Quality Insights of Pennsylvania
* §	0405/160	52v4	EHR	Process	Effective Clinical Care	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis	National Committee for Quality Assurance
§	0409/205	N/A	Registry	Process	Effective Clinical Care	HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
	0024/239	155v4	EHR	Process	Community/ Population Health	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity	National Committee for Quality Assurance
	0038/240	117v4	EHR	Process	Community/Population Health	Childhood Immunization Status Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday	National Committee for Quality Assurance
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS		CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
		Physical Medicine
!	N/A/ 109		N/A	Claims, Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain	American Academy of Orthopedic Surgeons
!	0420/131		N/A	Claims, Registry	Process	Communication and Care Coordination	Pain Assessment and Follow-Up Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
!	2624/182		N/A	Claims, Registry	Process	Communication and Care Coordination	Functional Outcome Assessment Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies	Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
§ !!	0052/312		166v5	Web Interface, EHR	Process	Efficiency and Cost Reduction	Use of Imaging Studies for Low Back Pain Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis	National Committee for Quality Assurance
	N/A/ 408		N/A	Registry	Process	Effective Clinical Care	Opioid Therapy Follow-up Evaluation All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 412		N/A	Registry	Process	Effective Clinical Care	Documentation of Signed Opioid Treatment Agreement All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 414		N/A	Registry	Process	Effective Clinical Care	Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record	American Academy of Neurology
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Plastic Surgery
!!	0268/021	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0239/023	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical 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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	N/A/ 358	N/A	Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Patient-Centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon	American College of Surgeons
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Preventive Medicine
* § !	0059/001	122v4	Claims, Web Interface, Registry, EHR	Intermediate Outcome	Effective Clinical Care	Diabetes: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period	National Committee for Quality Assurance
!	0045/024	N/A	Claims, Registry	Process	Communication and Care Coordination	Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
	0046/039	N/A	Claims, Registry	Process	Effective Clinical Care	Screening for Osteoporosis for Women Aged 65-85 Years of Age Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
	N/A/ 048	N/A	Claims, Registry	Process	Effective Clinical Care	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 109	N/A	Claims, Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Osteoarthritis (OA): Function and Pain Assessment Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain	American Academy of Orthopedic Surgeons
	0041/110	147v5	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Preventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization	American Medical Association-Physician Consortium for Performance Improvement
	0043/111	127v4	Claims, Web Interface, Registry, EHR	Process	Community/ Population Health	Pneumonia Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine	National Committee for Quality Assurance
* §	2372/112	125v4	Claims, Web Interface, Registry, EHR	Process	Effective Clinical Care	Breast Cancer Screening Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer	National Committee for Quality Assurance
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Neurology
	0325/032	N/A	Claims, Registry	Process	Effective Clinical Care	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) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an antithrombotic at discharge	American Academy of Neurology
*	1814/268	N/A	Claims, Registry	Process	Effective Clinical Care	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year	American Academy of Neurology
	N/A/ 281	149v4	EHR	Process	Effective Clinical Care	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	American Medical Association-Physician Consortium for Performance Improvement
*	N/A/ 282	N/A	Registry	Process	Effective Clinical Care	Dementia: Functional Status Assessment Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period	American Academy of Neurology/ American Psychiatric Association
*	N/A/ 283	N/A	Registry	Process	Effective Clinical Care	Dementia: Neuropsychiatric Symptom Assessment Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period	American Academy of Neurology/ American Psychiatric Association
*	N/A/ 284	N/A	Registry	Process	Effective Clinical Care	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	American Academy of Neurology/ American Psychiatric Association
* !	N/A/ 286	N/A	Registry	Process	Patient Safety	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	American Academy of Neurology/ American Psychiatric Association
* !	N/A/ 288	N/A	Registry	Process	Communication and Care Coordination	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	American Academy of Neurology/ American Psychiatric Association
*	N/A/ 290	N/A	Registry	Process	Effective Clinical Care	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	American Academy of Neurology
*	N/A/ 291	N/A	Registry	Process	Effective Clinical Care	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	American Academy of Neurology
* !	N/A/ 293	N/A	Registry	Process	Communication and Care Coordination	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	American Academy of Neurology
* !	N/A/ 294	N/A	Registry	Process	Communication and Care Coordination	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	American Academy of Neurology
!	N/A/ 386	N/A	Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually	American Academy of Neurology
	N/A/ 408	N/A	Registry	Process	Effective Clinical Care	Opioid Therapy Follow-up Evaluation All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 412	N/A	Registry	Process	Effective Clinical Care	Documentation of Signed Opioid Treatment Agreement All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record	American Academy of Neurology
	N/A/ 414	N/A	Registry	Process	Effective Clinical Care	Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record	American Academy of Neurology
!!	N/A/ 419	N/A	Claims, Registry	Efficiency	Efficiency and Cost Reduction	Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered	American Academy of Neurology
!	N/A/ 435	N/A	Claims, Registry	Outcome	Effective Clinical Care	Quality Of Life Assessment For Patients With Primary Headache Disorders Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved	American Academy of Neurology
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥		Measure Steward
Mental/Behavioral Health
	105/ 009	128v4	EHR	Process	Effective Clinical Care		Anti-Depressant Medication Management Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)		National Committee for Quality Assurance/American Heart Association
*	0418/134	N/A	Claims, Web Interface, Registry, EHR, Measures Groups	Process	Community/Population Health		Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen		Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
!	N/A/ 181	N/A	Claims, Registry	Process	Patient Safety		Elder Maltreatment Screen and Follow-Up Plan Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen		Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania
	N/A/ 281	149v4	EHR	Process	Effective Clinical Care		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		American Medical Association-Physician Consortium for Performance Improvement
*	N/A/ 282	N/A	Registry	Process	Effective Clinical Care		Dementia: Functional Status Assessment Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period		American Academy of Neurology/ American Psychiatric Association
*	N/A/ 283	N/A	Registry	Process	Effective Clinical Care		Dementia: Neuropsychiatric Symptom Assessment Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period		American Academy of Neurology/ American Psychiatric Association
*	N/A/ 284	N/A	Registry	Process	Effective Clinical Care		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		American Academy of Neurology/ American Psychiatric Association
* !	N/A/ 286	N/A	Registry	Process	Patient Safety		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		American Academy of Neurology/ American Psychiatric Association
* !	N/A/ 288	N/A	Registry	Process	Communication and Care Coordination		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		American Academy of Neurology/ American Psychiatric Association
!	N/A/ 325	N/A	Registry	Process	Communication/ Care Coordination		Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition		American Psychiatric Association/ American Medical Association-Physician Consortium for Performance Improvement
!	1879/383	N/A	Registry	Intermediate Outcome	Patient Safety		Adherence to Antipsychotic Medications for Individuals with Schizophrenia Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)		Health Services Advisory Group/ Centers for Medicare & Medicaid Services
!	0576/391	N/A	Registry	Process	Communication/ Care Coordination		Follow-up After Hospitalization for Mental Illness (FUH) The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge		National Committee for Quality Assurance
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Radiology
20a. Diagnostic Radiology
!!	N/A/ 145	N/A	Registry	Process	Patient Safety	Radiology: Exposure Time Reported for Procedures Using Fluoroscopy Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available)	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
!	0508/ 146	N/A	Claims, Registry	Process	Efficiency and Cost Reduction	Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening Percentage of final reports for screening mammograms that are classified as “probably benign”	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 147	N/A	Claims, Registry	Process	Communication and Care Coordination	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	American Medical Association-Physician Consortium for Performance Improvement/ Society of Nuclear Medicine and Molecular Imaging
	0507/ 195	N/A	Claims, Registry	Process	Effective Clinical Care	Radiology: Stenosis Measurement in Carotid Imaging Reports Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
!	0509/225	N/A	Claims, Registry	Structure	Communication and Care Coordination	Radiology: Reminder System for Screening Mammograms Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement
* !	N/A/ 359	N/A	Registry	Process	Communication and Care Coordination	Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems	American College of Radiology
* !!	N/A/ 360	N/A	Registry	Process	Patient Safety	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.	American College of Radiology
* !	N/A/ 361	N/A	Registry	Structure	Patient Safety	Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements	American College of Radiology
* !	N/A/ 362	N/A	Registry	Structure	Communication and Care Coordination	Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study This measure was finalized for inclusion in 2014 PQRS in the CY 2013 PFS Final Rule (see Table 52 at 78 FR 74667)	American College of Radiology
* !	N/A/ 363	N/A	Registry	Process	Communication and Care Coordination	Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed	American College of Radiology
* !!	N/A/ 364	N/A	Registry	Process	Communication and Care Coordination	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors	American College of Radiology
	N/A/ 405	N/A	Claims, Registry	Process	Effective Clinical Care	Appropriate Follow-up Imaging for Incidental Abdominal Lesions Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: • Liver lesion ≤ 0.5 cm • Cystic kidney lesion < 1.0 cm • Adrenal lesion ≤ 1.0 cm	American College of Radiology
!!	N/A/ 406	N/A	Claims, Registry	Process	Effective Clinical Care	Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients Percentage of final reports for computed tomography (CT) or magnetic resonance imaging (MRI) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended	American College of Radiology
	N/A/ 436	N/A	Claims, Registry	Process	Effective Clinical Care	Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique	American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
20b. Interventional Radiology
!	N/A/ 259	N/A	Registry	Outcome	Patient Safety	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)	Society for Vascular Surgeons
!	N/A/ 265	N/A	Registry	Process	Communication and Care Coordination	Biopsy Follow-Up Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician	American Academy of Dermatology
!	N/A/ 344	N/A	Registry	Outcome	Effective Clinical Care	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2	Society for Vascular Surgeons
!	N/A/ 345	N/A	Registry	Outcome	Effective Clinical Care	Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital	Society for Vascular Surgeons
20c. Radiation Oncology
* § !!	0389/102	129v5	Registry, EHR	Process	Efficiency and Cost Reduction	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer	American Medical Association-Physician Consortium for Performance Improvement
§ !	0384/143	157v4	Registry, EHR	Process	Person and Caregiver Centered Experience and Outcome	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	American Medical Association-Physician Consortium for Performance Improvement
!	0383/144	N/A	Registry	Process	Person and Caregiver Centered Experience and Outcome	Oncology: Medical and Radiation – Plan of Care for Pain Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain	American Society of Clinical Oncology
!!	0382/156	N/A	Claims, Registry	Process	Patient Safety	Oncology: Radiation Dose Limits to Normal Tissues Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues	American Society for Radiation Oncology
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Surgery
21a. Vascular Surgery
!	N/A/ 258	N/A	Registry	Outcome	Patient Safety	Rate of Open Elective Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) Percent of patients undergoing open repair of small or moderate sized non-ruptured abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)	Society for Vascular Surgeons
!	N/A/ 259	N/A	Registry	Outcome	Patient Safety	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged at Home by Post-Operative Day #2) Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)	Society for Vascular Surgeons
!	N/A/ 260	N/A	Registry	Outcome	Patient Safety	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2)	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	N/A/ 344	N/A	Registry	Outcome	Effective Clinical Care	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2	Society for Vascular Surgeons
!	N/A/ 345	N/A	Registry	Outcome	Effective Clinical Care	Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital	Society for Vascular Surgeons
!	1534/347	N/A	Registry	Outcome	Patient Safety	Rate of Endovascular Aneurysm Repair (EVAR of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital Percent of patients undergoing endovascular repair of small or moderate abdominal aortic aneurysms (AAA) who die while in the hospital	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
21b. General Surgery
!!	0268/021	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalasporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, which had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0271/022	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Discontinuation of Prophylactic Parenteral 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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
!	0239/023	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical 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	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
* !	N/A/ 354	N/A	Registry	Outcome	Patient Safety	Anastomotic Leak Intervention Percentage patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery	American College of Surgeons
* !	N/A/ 355	N/A	Registry	Outcome	Patient Safety	Unplanned Reoperation within the 30 Day Postoperative Period Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period	American College of Surgeons
* !	N/A/ 356	N/A	Registry	Outcome	Effective Clinical Care	Unplanned Hospital Readmission within 30 Days of Principal Procedure Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure	American College of Surgeons
* !	N/A/ 357	N/A	Registry	Outcome	Effective Clinical Care	Surgical Site Infection (SSI) Percentage of patients aged 18 years and older who had a surgical site infection (SSI)	American College of Surgeons
!	N/A/ 358	N/A	Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Patient-Centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon	American College of Surgeons
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Thoracic Surgery
!!	0268/021	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis	American Medical Association-Physician Consortium for Performance/ National Committee for Quality Assurance
!	0239/023	N/A	Claims, Registry	Process	Patient Safety	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical 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	American Medical Association-Physician Consortium for Performance/ National Committee for Quality Assurance
!	0129/164	N/A	Registry	Outcome	Effective Clinical Care	Coronary Artery Bypass Graft (CABG): Prolonged Intubation Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours	American Thoracic Society
* !	0130/165	N/A	Registry	Outcome	Effective Clinical Care	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	American Thoracic Society
* !	0131/166	N/A	Registry	Outcome	Effective Clinical Care	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	American Thoracic Society
* !	0114/167	N/A	Registry	Outcome	Effective Clinical Care	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	American Thoracic Society
* !	0115/168	N/A	Registry	Outcome	Effective Clinical Care	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	Society of Thoracic Surgeons
* !	N/A/ 357	N/A	Registry	Outcome	Effective Clinical Care	Surgical Site Infection (SSI) Percentage of patients aged 18 years and older who had a surgical site infection (SSI)	American College of Surgeons
!	N/A/ 358	N/A	Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Patient-Centered Surgical Risk Assessment and Communication  Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon	American College of Surgeons
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	Measure Type	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
Urology
	N/A/ 048	N/A	Claims, Registry	Process	Effective Clinical Care	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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
!	N/A/ 050	N/A	Claims, Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Urinary Incontinence: Assessment of Presence or Absence 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	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
* § !!	0389/ 102	129v5	Registry, EHR	Process	Efficiency and Cost Reduction	Prostate Cancer: Avoidance of Overuse of Bone Scan for staging Low Risk Prostate Cancer Patients Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer	American Medical Association-Physician Consortium for Performance Improvement
	0390/ 104	N/A	Registry	Process	Effective Clinical Care	Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or very High Risk Prostate Cancer Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist	American Medical Association-Physician Consortium for Performance Improvement/ American Urological Association Education and Research
!	N/A/ 265	N/A	Registry	Process	Communication and Care Coordination	Biopsy Follow-Up Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician	American Academy of Dermatology
* !	N/A/ 357	N/A	Registry	Outcome	Effective Clinical Care	Surgical Site Infection (SSI) Percentage of patients aged 18 years and older who had a surgical site infection (SSI)	American College of Surgeons
!	N/A/ 358	N/A	Registry	Process	Person and Caregiver-Centered Experience and Outcomes	Patient-Centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon	American College of Surgeons
Cross-cutting measure requirement: In addition to reporting measures within the specialty measure set, MIPS eligible clinicians that have face-to-face encounters and are considered patient-facing providers, must report at least one cross-cutting measure from the cross-cutting measures list in Table C.

TABLE F: 2016 PQRS Measures Proposed for Removal for MIPS Reporting in 2017

MIPS ID Number	NQF/ PQRS	CMS E-Measure ID	Data Submission Method	National Quality Strategy Domain	Measure Title and Description¥	Measure Steward
	N/A/ 002	163v4	EHR	Effective Clinical Care	Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL) Percentage of patients 18–75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dL) during the measurement period Rationale: This measure no longer reflects evidence. CMS proposes removal of measure because it no longer reflects clinical guidelines and evidence. Clinical guidelines are better represented by PQRS # 438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease.	National Committee for Quality Assurance
!	0271/ 022	N/A	Claims, Registry	Patient Safety	Perioperative Care: Discontinuation of Prophylactic Parenteral 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 Rationale: CMS proposes to remove this measure because it is considered low bar and is part of standard clinical practice. There is no significant performance gap for this measure as indicated by high performance rates. Removing this measure will not significantly impact surgeons’ ability to report.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
	NA/ 041	NA		Effective Clinical Care	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 Rationale: The measure steward will no longer support stewardship of this measure. Measures implemented in the quality measure program are required to be updated annually by the measure steward. Since the measure steward has removed its support to update this measure in 2017, CMS proposes removal of the measure.	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
	0047/ 053	N/A	Registry, Measures Group	Effective Clinical Care	Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication Rationale: CMS proposes removal of this measure because it is being replaced by NQF 1799: Medication Management for People with Asthma. NQF #1799 is a measure included on collaborative core set.	American Academy of Allergy, Asthma, and Immunology/ American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
	0090/ 054	N/A	Claims, Registry	Effective Clinical Care	Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic 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 electrocardiogram (ECG) performed Rationale: CMS proposes to remove this measure because it is considered low bar and is part of standard clinical practice. There is no significant performance gap for this measure as indicated by high performance rates. Removal of this measure does not impact the number of adequate measures for Emergency Department Physicians.	American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance
	0387/ 071	CMS140v4	Claims, Registry, EHR, Measures Group	Effective Clinical Care	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 Rationale: Due to the agreement with the Core Measure Collaborative, CMS proposes to remove this measure as it is similar to a core measure. This measure is closely related to one of the core measures covered under the Core Measure Collaborative and is not included in the core measure set. Additionally, the clinical performance identified with this measure can be addressed by the measures within the core measure set.	American Medical Association-Physician Consortium for Performance Improvement/American Society of Clinical Oncology/ National Comprehensive Cancer Network
	0385 /072	CMS141v5	Claims, Registry, EHR, Measures Group	Effective Clinical Care	Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period Rationale: Due to the agreement with the Core Measure Collaborative, CMS proposes to remove this measure as it is similar to a core measure. This measure is closely related to one of the core measures covered under the Core Measure Collaborative and is not included in the core measure set. Additionally, the clinical performance identified with this measure can be addressed by the measures within the core measure set.	American Medical Association-Physician Consortium for Performance Improvement/American Society of Clinical Oncology/ National Comprehensive Cancer Network
	0395/ 084	N/A	Measures Group	Effective Clinical Care	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 started antiviral treatment within the 12 month reporting period for whom quantitative hepatitis C virus (HCV) ribonucleic acid (RNA) testing was performed within 12 months prior to initiation of antiviral treatment Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Medical Association-Physician Consortium for Performance Improvement /American Gastroenterological Association
	0396/ 085	N/A	Measures Group	Effective Clinical Care	Hepatitis C: Hepatitis C Virus (HCV) Genotype Testing Prior to Treatment Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom hepatitis C virus (HCV) genotype testing was performed within 12 months prior to initiation of antiviral treatment Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Medical Association-Physician Consortium for Performance Improvement /American Gastroenterological Association
	0398/ 087	N/A	Measures Group	Effective Clinical Care	Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation 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 hepatitis C virus (HCV) ribonucleic acid (RNA) testing was performed between 4-12 weeks after the initiation of antiviral treatment Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Academy of Neurology/ American Psychiatric Association
	0054/ 108	N/A	Measures Group	Effective Clinical Care	Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy Percentage of patients aged 18 years and older who were diagnosed with rheumatoid arthritis and were prescribed, dispensed, or administered at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD) Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	National Committee for Quality Assurance
	N/A/ 121	N/A	Registry, Measures Group	Effective Clinical Care	Adult Kidney Disease: Laboratory Testing (Lipid Profile) Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period Rationale: CMS proposes removal of this measure because it is considered a low bar measure and is part of standard clinical practice. There is no significant performance gap for this measure as indicated by high performance rates.	Renal Physicians Association
	0399/ 183	N/A	Measures Group	Community/ Population Health	Hepatitis C: Hepatitis A Vaccination Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure, this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
	N/A/ 241	182v5	EHR	Effective Clinical Care	Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dL) Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dL) Rationale: This measure no longer reflects evidence. CMS proposes removal of measure because it no longer reflects clinical guidelines and evidence. Clinical guidelines are better represented by PQRS # 438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease.	National Committee for Quality Assurance
	N/A/ 242	N/A	Measures Group	Effective Clinical Care	Coronary Artery Disease (CAD): Symptom Management Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period with results of an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
	N/A/ 270	N/A	Registry, Measures Group	Effective Clinical Care	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 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills that have been prescribed corticosteroid sparing therapy within the last twelve months Rationale: Due to the agreement with the Core Measure Collaborative, CMS proposes to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.	American Gastroenterological Association
	N/A/ 274	N/A	Registry, Measures Group	Effective Clinical Care	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 (IBD) for whom a tuberculosis (TB) screening was performed and results interpreted within six months prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy Rationale: Due to the agreement with the Core Measure Collaborative, CMS proposes to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.	American Gastroenterological Association
	N/A/ 280	N/A	Measures Group	Effective Clinical Care	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 Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Academy of Neurology/ American Psychiatric Association
	N/A/ 287	N/A	Measures Group	Effective Clinical Care	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 the alternatives to driving at least once within a 12 month period Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association
	N/A/ 289	N/A	Measures Group	Effective Clinical Care	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 that can produce Parkinson-like 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 Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Academy of Neurology
	N/A/ 292	N/A	Measures Group	Effective Clinical Care	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 Rationale: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the proposed MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS proposes to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.	American Academy of Neurology
	0036/ 311	126v4	EHR	Effective Clinical Care	Use of Appropriate Medications for Asthma Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period Rationale: This measure has a high performance rate and shows little variation in care. CMS proposes removal of measure because it has a high performance rate and is clinically close to another measure that is being proposed, NQF 1799: Medication Management for people with Asthma.	National Committee for Quality Assurance
	2083/ 339	N/A	Measures Group	Effective Clinical Care	Prescription of HIV Antiretroviral Therapy Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year Rationale: Due to the agreement with the Core Measure Collaborative, CMS proposes to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.	Health Resources and Services Administration
	N/A/ 365	148v4	EHR	Effective Clinical Care	Hemoglobin A1c Test for Pediatric Patients Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period Rationale: CMS proposes removal of this measure because the measure owner is no longer supporting implementation. Additionally, the evidence for this measure is no longer supported by clinical experts and guidance.	National Committee for Quality Assurance
	N/A/ 368	62v4	EHR	Effective Clinical Care	HIV/AIDS: Medical Visit Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit Rationale: According to clinical experts, this measure no longer reflects the evidence. CMS proposes removal of measure because it no longer reflects clinical guidelines and evidence.	National Committee for Quality Assurance
!	N/A/ 380	CMS179v4	EHR	Patient Safety	ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range Average percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR) during the measurement period Rationale: Since its implementation, this measure has had difficulty with feasibility. CMS proposes this measure be removed because it is not technically feasible to implement.	Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
	N/A/ 381	77v4	EHR	Effective Clinical Care	HIV/AIDS: RNA Control for Patients with HIV Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/mL. Rationale: According to clinical experts, this measure no longer reflects the evidence. CMS proposes removal of measure because it no longer reflects clinical guidelines and evidence.	Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
	2452/ 399	N/A	Registry	Effective Clinical Care	Post-Procedural Optimal Medical Therapy Composite (Percutaneous Coronary Intervention) Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge Rationale: The measure steward will no longer support stewardship of this measure. Measures implemented in the quality measure program are required to be updated annually by the measure steward. Since the measure steward has removed its support to update this measure in 2017, CMS proposes removal of the measure.	American College of Cardiology/American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
	N/A/ 425	N/A	Claims, Registry	Effective Clinical Care	Photodocumentation of Cecal Intubation The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination Rationale: Due to the agreement with the Core Measure Collaborative, CMS proposes to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.	American College of Gastroenterology/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy

TABLE G: Measures Proposed with Substantive Changes for MIPS Reporting in 2017

Measure Title:	Diabetes: Hemoglobin A1c Poor Control
MIPS ID Number:	N/A
NQF/PQRS #:	0059/001
CMS E-Measure ID:	CMS122v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data Submission Method:	Claims, Web Interface, Registry, EHR, Measures Group
Current Measure Description:	Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Proposed Substantive Change	Revise Measure Title to read: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) Revise data submission method to remove Measures Group
Steward:	National Committee for Quality Assurance
Rationale:	CMS proposes a change to measure description that would clarify the definition of Hemoglobin A1c required for poor control. This change does not constitute a change in measure intent or logic coding. Hemoglobin A1c >9.0% is consistent with clinical guidelines and practice. Additionally, in response to the proposed MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method.
Measure Title:	Coronary Artery Disease (CAD): Antiplatelet Therapy
MIPS ID Number:	N/A
NQF/PQRS #:	0067/006
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data Submission Method:	Registry, Measures Group
Current Measure Description:	Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Proposed Substantive Change	Revise Measure Title to read: Chronic Stable Coronary Artery Disease (CAD): Antiplatelet Therapy Revise data submission method to remove Measures Group
Steward:	National Committee for Quality Assurance
Rationale:	CMS proposes a change to measure title to align with the NQF endorsed version of this measure and to clarify the intent of the measure. This change does not constitute a change in measure intent. The measure description remains the same where patients diagnosed with CAD are prescribed an antiplatelet within 12 months. Additionally, in response to the proposed MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method.
Measure Title:	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
MIPS ID Number:	N/A
NQF/PQRS #:	0083/008
CMS E-Measure ID:	CMS144v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data Submission Method:	Web Interface, Registry, EHR, Measures Group
Current Measure Description:	Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Proposed Substantive Change	Revise data submission method to remove from the Web Interface
Steward:	American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association
Rationale:	CMS proposes to change the reporting mechanism for this measure by removing it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the core measure set. This measure is not a measure in the core set and is being proposed for removal from the Web Interface to align the Web Interface measure set with the core measure set.
Measure Title:	Medication Reconciliation Post-Discharge
MIPS ID Number:	N/A
NQF/PQRS #:	0097/046
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data Submission Method:	Claims, Registry
Current Measure Description:	The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record This measure is reported as three rates stratified by age group: • Reporting Criteria 1: 18-64 years of age • Reporting Criteria 2: 65 years and older • Total Rate: All patients 18 years of age and older
Proposed Substantive Change	Revise data submission method to add the Web Interface
Steward:	National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes to change the data submission method for this measure by adding it to the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the core measure set. This measure is a core measure and is being proposed for the Web Interface to align the Web Interface measure set with the core measure set. Furthermore, this measure is replacing PQRS #130: Documentation of Current Medications in the Medical Record in the Web Interface.
Measure Title:	Appropriate Testing for Children with Pharyngitis
MIPS ID Number:	N/A
NQF/PQRS #:	N/A (previously 0002)/066
CMS E-Measure ID:	CMS146v4
National Quality Strategy Domain:	Efficiency and Cost Reduction
Current Data submission Method:	Registry, EHR
Current Measure Description:	Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode
Proposed Substantive Change	Revise Measures description to read: Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode Remove NQF #0002
Steward:	National Committee on Quality Assurance
Rationale:	CMS proposes the change in the measure description due to guideline changes in 2013 where the age range changed to 3-18. Furthermore, this measure is no longer endorsed by the National Quality Forum (NQF), therefore, CMS proposes to remove the NQF number as a reference for this measure.
Measure Title:	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
MIPS ID Number:	N/A
NQF/PQRS #:	0389/102
CMS E-Measure ID:	CMS129v5
National Quality Strategy Domain:	Efficiency and Cost Reduction
Current Data submission Method:	Registry, EHR
Measure Description:	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
Proposed Substantive Change	Revise measure description to read: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
Steward:	American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes changes to the measure description due to a change in clinical guidelines that in include very low and low risk of prostate cancer recurrence. CMS believes that this change does not change the intent of the measure but merely ensures the measure remains up-to-date according to clinical guidelines and practice.
Measure Title:	Breast Cancer Screening
MIPS ID Number:	N/A
NQF/PQRS #:	2372 (previously not applicable)/112
CMS E-Measure ID:	CMS125v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Claims, Web Interface, Registry, EHR, Measures Group
Current Measure Description:	Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer
Proposed Substantive Change	Revise Measures description to read: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer Add NQF # 2372 which was not previously applicable Revise data submission method to remove Measures Group
Steward:	National Committee on Quality Assurance
Rationale:	CMS proposes a substantive change to the measure due to clinical guideline changes that occurred in 2013 which changed the age requirement for mammograms from 40-69 years to 50-74 years. CMS believes that this change does not change the intent of the measure but merely ensures the measure remains up-to-date according to clinical guidelines and practice. Additionally, in response to the proposed MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method. Furthermore, this measure has been recently endorsed by NQF with the updated age range. Therefore, CMS proposes to add the NQF #2372 to the measure.
Measure Title:	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
MIPS ID Number:	N/A
NQF/PQRS #:	0066/118
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Web Interface, Registry
Current Measure Description:	Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy
Proposed Substantive Change	Revise data submission method to remove from the Web Interface
Steward:	American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes to change the data submission method for this measure by removing it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the core measure set. This measure is not a measure in the core set and is being proposed for removal from the Web Interface to align the Web Interface measure set with the core measure set.
Measure Title:	Diabetes: Urine Protein Screening
MIPS ID Number:	N/A
NQF/PQRS #:	0062/119
CMS E-Measure ID:	CMS134v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Registry, EHR, Measures Group
Current Measure Description:	The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Proposed Substantive Change	Revise measure title to read: Diabetes: Medical Attention for Nephropathy Revise data submission method to remove Measures Group
Steward:	National Committee for Quality Assurance
Rationale:	CMS proposes the title of this measure change to align with the measure’s intent to increase reporting clarity and to match the NQF endorsed measure’s title. Additionally, in response to the proposed MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method.
Measure Title:	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
MIPS ID Number:	N/A
NQF/PQRS #:	0421/128
CMS E-Measure ID:	CMS69v4
National Quality Strategy Domain:	Community/Population Health
Current Data submission Method:	Claims, Web Interface, Registry, Measures Group
Measure Description:	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: -Age 65 years and older BMI => 23 and < 30 kg/m2 -Age 18 - 64 years BMI => 18.5 and < 25 kg/m2
Proposed Substantive Change	Remove upper parameter from measure description. Revise description to read: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 - 64 years BMI => 18.5 and < 25 kg/m2 Revise data submission method to remove Measures Group
Steward:	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
Rationale:	CMS proposes to remove the upper parameter from the measure description to align with the recommendations of technical expert panel and clinical expertise. Additionally, in response to the proposed MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method.
Measure Title:	Documentation of Current Medications in the Medical Record
MIPS ID Number:	N/A
NQF/PQRS #:	0419/130
CMS E-Measure ID:	CMS68v5
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Claims, Web Interface, Registry, EHR, Measures Group
Measure Description:	Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration
Proposed Substantive Change	Revise data submission method to remove from the Web Interface and Measures Group. Measure will remain reportable via Claims, EHR, and Registry
Steward:	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
Rationale:	CMS proposes to revise the data submission method of this measure to remove it from use in the Web Interface. This measure is being replaced in the Web Interface with the core measure, PQRS #46: Medication Reconciliation Post-Discharge. Since these measures cover similar topic areas, CMS proposes to remove this measure from the Web Interface. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group.
Measure Title:	Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
MIPS ID Number:	N/A
NQF/PQRS #:	0418/134
CMS E-Measure ID:	CMS2v5
National Quality Strategy Domain:	Community/Population Health
Current Data submission Method:	Claims, Web Interface, Registry, EHR, Measures Group
Measure Description:	Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Proposed Substantive Change	Revise measure title to read: Preventive Care and Screening: Screening for Depression and Follow-Up Plan Revise measure description to read: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Revise data submission method to remove from Measures Group
Steward:	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
Rationale:	CMS proposes the substantive change to revise the title and measure description to align with the recommendations of technical expert panel and clinical expertise in the field. CMS believes the revision provides clarity to providers when reporting. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group.
Measure Title:	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
MIPS ID Number:	N/A
NQF/PQRS #:	0405/160
CMS E-Measure ID:	52v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	EHR, Measures Group
Measure Description:	Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis
Proposed Substantive Change	Change data submission method to remove Measures Group and have this measure be reportable as EHR only
Steward:	National Committee for Quality Assurance
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group to EHR only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group.
Measure Title:	Diabetes: Foot Exam
MIPS ID Number:	N/A
NQF/PQRS #:	0056/163
CMS E-Measure ID:	CMS123v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	EHR
Current Measure Description:	Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period
Proposed Substantive Change	Revise measure description to read: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year
Steward:	National Committee for Quality Assurance
Rationale:	CMS proposes to revise the measure description to improve clarity for providers about what constitutes a foot exam. CMS believes this change does not change the intent of the measure, but merely provides clarity in response to provider feedback.
Measure Title:	Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
MIPS ID Number:	N/A
NQF/PQRS #:	0130/165
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	Society of Thoracic Surgeons
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Coronary Artery Bypass Graft (CABG): Stroke
MIPS ID Number:	N/A
NQF/PQRS #:	0131/166
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	Society of Thoracic Surgeons
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
MIPS ID Number:	N/A
NQF/PQRS #:	0114/167
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	Society of Thoracic Surgeons
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
MIPS ID Number:	N/A
NQF/PQRS #:	0115/168
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	Society of Thoracic Surgeons
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Rheumatoid Arthritis (RA): Tuberculosis Screening
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/176
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Rheumatology
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/177
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months
Proposed Substantive Change	Change data submission method from Measures Group only to Registry reporting
Steward:	American College of Rheumatology
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/179
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Rheumatology
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Rheumatoid Arthritis (RA): Glucocorticoid Management
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/180
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Rheumatology
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Stroke and Stroke Rehabilitation: Thrombolytic Therapy
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/187
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Registry
Current Measure Description:	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
Proposed Substantive Change	Change measure type from outcome measure to process measure
Steward:	American Society of Anesthesiologists/ The Joint Commission
Rationale:	CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure.
Measure Title:	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
MIPS ID Number:	N/A
NQF/PQRS #:	0068/204
CMS E-Measure ID:	CMS164v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Claims, Web Interface, Registry, EHR, Measures Group
Current Measure Description:	Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period
Proposed Substantive Change	Revise measure title to read: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Revise measure description to read: Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period Revise data submission method to remove from Measures Group
Steward:	National Committee for Quality Assurance
Rationale:	CMS proposes to revise the measure title and description to align with the measure’s intent and to provide clarity for providers. Additionally, in response to the proposed MIPS policy to no longer include measure groups as a data submission method, this measure is being removed from measure group.
Measure Title:	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0422/217
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Process
Current Measure Description:	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
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with Knee Impairments Revise measure description to read: A self-report measure of change in functional status for patients 18 year+ with knee impairments. The change in functional status assessed using FOTO’s (knee) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality Revise measure type from a process measure to an outcome measure
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the change in functional status score and denominator details that include patients that completed the FOTO knee FS PROM at admission and discharge. Additionally, this change in numerator and denominator details entails that the measure type changes from process to outcome
Measure Title:	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0423/218
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Outcome
Current Measure Description:	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
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with Hip Impairments Revise measure description to read: A self-report measure of change in functional status for patients 18 years+ with hip impairments. The change in functional status assessed using FOTO’s (hip) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average change in functional status scores in patients who were treated in a 12 month period and denominator details that include patients that completed the FOTO hip FS PROM at admission and discharge.
Measure Title:	Functional Deficit: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0424/219
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Outcome
Current Measure Description:	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
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with Foot and Ankle Impairments Revise measure description to read: A self-report measure of change in functional status for patients 18 years+ with foot and ankle impairments. The change in functional status assessed using FOTO’s (foot and ankle) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average change in functional status score in patients who were treated in a 12-month period and denominator details that include patients that completed the FOTO foot and ankle PROM at admission and discharge.
Measure Title:	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0425/220
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Outcome
Current Measure Description:	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 Risk-Adjusted Functional Status is measured
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with Lumbar Impairments Revise measure description to read: A self-report outcome measure of functional status for patients 18 years+ with lumbar impairments. The change in functional status assessed using FOTO’s (lumbar) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status score for patients treated in a 12-month period compared to a standard threshold and denominator details that include patients that completed the FOTO (lumbar) PROM.
Measure Title:	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0426/221
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Outcome
Current Measure Description:	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 Risk-Adjusted Functional Status is measured
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with Shoulder Impairments Revise measure description to read: A self-report outcome measure of change in functional status for patients 18 years+ with shoulder impairments. The change in functional status assessed using FOTO’s (shoulder) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status score in patients treated in a 12-month period and denominator details that include patients that completed the FOTO shoulder FS outcome instrument at admission and discharge.
Measure Title:	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0427/222
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Outcome
Current Measure Description:	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
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with Elbow, Wrist and Hand Impairments Revise measure description to read: A self-report outcome measure of functional status for patients 18 years+ with elbow, wrist and hand impairments. The change in functional status assessed using FOTO’s (elbow, wrist and hand) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status scores for patients treated over a 12 month period and denominator details that include patients that completed the FOTO (elbow, wrist, and hand) PROM.
Measure Title:	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments
MIPS ID Number:	N/A
NQF/PQRS #:	0428/223
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Registry
Current Measure Type:	Outcome
Current Measure Description:	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
Proposed Substantive Change	Revise measure title to read: Functional Status Change for Patients with General Orthopedic Impairments Revise measure description to read: A self-report outcome measure of functional status for patients 18 years+ with general orthopedic impairments. The change in functional status assessed using FOTO (general orthopedic) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Steward:	Focus on Therapeutic Outcomes, Inc.
Rationale:	CMS proposes to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the change in functional status scores for patients over a 12 month period and denominator details that include patients that completed the FOTO (general orthopedic) PROM.
Measure Title:	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
MIPS ID Number:	N/A
NQF/PQRS #:	1814/268
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Claims, Registry
Current Measure Description:	All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year
Proposed Substantive Change	Change measure type from outcome measure to process measure
Steward:	American Academy of Neurology
Rationale:	CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS proposes to revise the classification of this measure to process measure. This would be consistent with the clinical action required for the measure and would align the measure type with the NQF-endorsed version.
Measure Title:	Sleep Apnea: Assessment of Sleep Symptoms
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/276
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Sleep Apnea: Assessment of Sleep Symptoms
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/277
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measure Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Sleep Apnea: Positive Airway Pressure Therapy Prescribed
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/278
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/279
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Dementia: Functional Status Assessment
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/282
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Neurology/ American Psychiatric Association
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Dementia: Neuropsychiatric Symptom Assessment
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/283
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Neurology/ American Psychiatric Association
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Dementia: Management of Neuropsychiatric Symptoms
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/284
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Neurology/ American Psychiatric Association
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Dementia: Counseling Regarding Safety Concerns
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/286
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Neurology/ American Psychiatric Association
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Dementia: Caregiver Education and Support
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/288
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American Academy of Neurology/ American Psychiatric Association
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/290
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Academy of Neurology
Rationale:	CMS proposes to change the data submission for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS proposes to revise the classification of this measure to process measure to match the clinical action of psychiatric disease assessment.
Measure Title:	Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/291
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction at least annually
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Academy of Neurology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of assessment of cognitive impairment.
Measure Title:	Parkinson’s Disease: Rehabilitative Therapy Options
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/293
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Academy of Neurology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of communication about therapy options.
Measure Title:	Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/294
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	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
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Academy of Neurology
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of communicating treatment options.
Measure Title:	Cervical Cancer Screening
MIPS ID Number:	N/A
NQF/PQRS #:	0032/309
CMS E-Measure ID:	CMS124v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	EHR
Current Measure Description:	Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer
Proposed Substantive Change	Revise Measure description to read: Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21–64 who had cervical cytology performed every 3 years Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Steward:	National Committee on Quality Assurance
Rationale:	CMS proposes to change the measure description of this measure to align with measure intent and 2012 USPSTF recommendation: U.S. Preventive Services Task Force. 2012. "Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement." Ann Intern Med. 156(12):880-91.
Measure Title:	Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/317
CMS E-Measure ID:	CMS22v4
National Quality Strategy Domain:	Community/Population Health
Current Data submission Method:	Claims, Web Interface, Registry, EHR, Measures Group
Current Measure Description:	Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
Proposed Substantive Change	Revise data submission method to remove from Web Interface and Measures Group
Steward:	Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania
Rationale:	CMS proposes a change to the data submission method for this measure and remove it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the core measure set. This measure is not a core measure and is being removed to align the Web Interface measure set with the core measure set. Additionally, in response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group.
Measure Title:	Pediatric Kidney Disease: Adequacy of Volume Management
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/327
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Registry
Measure Description:	Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist.
Proposed Substantive Change	Change measure type from outcome measure to process measure
Steward:	Renal Physicians Association
Rationale:	CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS understands this measure to be a percentage of documented assessment rather than a health outcome. Therefore, CMS proposes to revise the classification of this measure to process.
Measure Title:	HIV Viral Load Suppression
MIPS ID Number:	N/A
NQF/PQRS #:	2082/338
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	Health Resources and Services Administration
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	HIV Medical Visit Frequency
MIPS ID Number:	N/A
NQF/PQRS #:	2079/340
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Efficiency and Cost Reduction
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	Health Resources and Services Administration
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/350
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Association of Hip and Knee Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of shared decision-making.
Measure Title:	Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/351
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients regardless of age or gender undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Association of Hip and Knee Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure.
Measure Title:	Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/352
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Association of Hip and Knee Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure.
Measure Title:	Total Knee Replacement: Identification of Implanted
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/353
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients regardless of age or gender undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant
Proposed Substantive Change	Change data submission method from Measures Group only to Registry Change measure type from outcome measure to process measure
Steward:	American Association of Hip and Knee Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measure Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure.
Measure Title:	Anastomotic Leak Intervention
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/354
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Unplanned Reoperation within the 30 Day Postoperative Period
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/355
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period
Proposed Substantive Change	Change data submission measure from Measures Group only to Registry
Steward:	American College of Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Unplanned Hospital Readmission within 30 Days of Principal Procedure
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/356
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Surgical Site Infection (SSI)
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/357
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Measures Group
Measure Description:	Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Surgeons
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/359
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Radiology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/360
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Radiology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/361
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Patient Safety
Current Data submission Method:	Measures Group
Measure Description:	Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry AND that include at a minimum selected data elements
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Radiology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/362
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Radiology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/363
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Radiology
Rationale:	CMS proposes to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/364
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Communication and Care Coordination
Current Data submission Method:	Measures Group
Measure Description:	Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
Proposed Substantive Change	Change data submission method from Measures Group only to Registry
Steward:	American College of Radiology
Rationale:	CMS proposes to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the proposed MIPS policy to no longer include Measures Group as a data submission method, this measure is being proposed as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
Measure Title:	Depression Remission at Twelve Months
MIPS ID Number:	N/A
NQF/PQRS #:	0710/370
CMS E-Measure ID:	CMS159v4
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Web interface, Registry, EHR
Measure Description:	Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment
Proposed Substantive Change	Revise measure description to read: Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days) after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. Change measure type from intermediate outcome measure to outcome measure
Steward:	Minnesota Community Measurement
Rationale:	CMS proposes to revise the measure description to provide clarity for reporting. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. Additionally, CMS proposes to change this measure type designation from intermediate outcome measure to outcome measure. This measure was previously finalized in PQRS as an intermediate outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to outcome measure in order to match the outcome of depression remission.
Measure Title:	Functional Status Assessment for Knee Replacement
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/375
CMS E-Measure ID:	CMS66v4
National Quality Strategy Domain:	Person and Caregiver-Centered Experience and Outcomes
Current Data submission Method:	EHR
Measure Description:	Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments.
Proposed Substantive Change	Revise measure title to read: Functional Status Assessment for Total Knee Replacement Revise measure description to read: Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments
Steward:	Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
Rationale:	CMS proposes to revise the title and description of the measure to align with the intent of the measure. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians.
Measure Title:	Functional Status Assessment for Hip Replacement
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/376
CMS E-Measure ID:	CMS56v4
National Quality Strategy Domain:	Person and Caregiver-Centered Experience and Outcomes
Current Data submission Method:	EHR
Measure Description:	Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments
Proposed Substantive Change	Revise title to read: Functional Status Assessment for Total Hip Replacement Revise measure description to read: Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments
Steward:	Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance
Rationale:	CMS proposes to revise the title and description of the measure to align with the intent of the measure. This change addresses concerns does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians.
Measure Title:	Functional Status Assessment for Complex Chronic Conditions
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/377
CMS E-Measure ID:	CMS90v5
National Quality Strategy Domain:	Person and Caregiver-Centered Experience and Outcomes
Current Data submission Method:	EHR
Measure Description:	Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments
Proposed Substantive Change	Revise measure title to read: Functional Status Assessments for Patients with Congestive Heart Failure Revise measure description to read: Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Steward:	Centers for Medicare & Medicaid Services/ Mathematica
Rationale:	CMS proposes to revise the title and description of the measure to add clarity in response to provider feedback. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians.
Measure Title:	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/420
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Registry
Current Measure Description:	Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.
Proposed Substantive Change	Change measure type from process measure to outcome measure
Steward:	Society of Interventional Radiology
Rationale:	CMS proposes to change this measure type designation from process measure to outcome measure. This measure was previously finalized in PQRS as a process measure. However, upon further review and analysis of the measure specification, CMS proposes to revise the classification of this measure to outcome measure because it assesses improvement on a patient reported outcome survey instrument.
Measure Title:	Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal
MIPS ID Number:	N/A
NQF/PQRS #:	N/A/421
CMS E-Measure ID:	N/A
National Quality Strategy Domain:	Effective Clinical Care
Current Data submission Method:	Registry
Current Measure Description:	Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts
Proposed Substantive Change	Change measure type from outcome measure to process measure
Steward:	Society of Interventional Radiology
Rationale:	CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of appropriate care assessment.

A37