Crosswalk - Measures under Consideration 2020, Data Template for Candidate Measures

QCDR Measure Submission Template
CY 2020 Final versus CY 2021 Proposed

Burden impact: The changes to this form do not reflect proposals in the CY2021 Physician Fee
Schedule (PFS) Proposed Rule for the Quality Payment Program. There are no impacts to
burden as a result of any changes reflected here.
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Change #1:
Location: Page 1
Reason for Change:
Added instructions at the top of the file because of change from Jira online platform data
collection to e-mail based data collection for 2020 only.
CY 2020 Final Rule text:
None
CY 2021 Proposed Rule text:
Instructions:
1.
Complete the measure template below by entering your candidate measure
information in the column titled “Add Your Content Here.”
2.
All rows that have an asterisk symbol * in the Field Label require a response.
These rows also appear unshaded.
3.
All rows shaded in gray are optional. You are encouraged to complete all rows
that are applicable to your measure.
4.
For each row, the “Guidance” column provides details about how to complete the
form and what kind of data to include in your response.
5.
For check boxes, note whether the field is “select one” or “select all that apply.”
You can click on the box to place or remove the “X.”
6.
If you have lengthy text to insert, place the text at the bottom of the form, clearly
indicating your intended row number or field label.
7.
Send completed templates and any accompanying files (e.g., MIPS Peer Review
Journal Article attachment, testing data, MAT information) by June 30, 2020 to
[email protected]
8.
If you need to submit a measure change, please use the “Review” tab in Word
and select “Track Changes” or highlight any updates you made to the measure, then by
September 4, 2020, send the revised template to [email protected]
*****
Change #2:
Location: All pages
Reason for Change:
To save space, this column and its contents were replaced by an asterisk symbol in the
“Field Label” column.
CY 2020 Final Rule text:
Column: Req’d [Required]
CY 2021 Proposed Rule text:
[Deleted this column]

*****
Change #3:
Location: All pages
Reason for Change:
Changed column header because of the change from Jira online platform data collection
to e-mail based data collection for 2020 only.
CY 2020 Final Rule text:
Column: Screen Guidance
CY 2021 Proposed Rule text:
[Changed column header to read: Guidance]
*****
Change #4:
Location: All pages
Reason for Change:
To save space, this column and its contents were deleted. It had formerly contained user
guidance such as “free text,” “select one,” or “select all that apply.” If needed for clarity,
this guidance was adapted into the “Field Label” or “Guidance” or “ADD YOUR
CONTENT HERE” fields.
CY 2020 Final Rule text:
Column: Data Form
CY 2021 Proposed Rule text:
[Deleted this column]
*****
Change #5:
Location: All pages
Reason for Change:
To save space, this column deleted, and its contents were adapted to the “ADD YOUR
CONTENT HERE” column.
CY 2020 Final Rule text:
Column: Possible Values
CY 2021 Proposed Rule text:
[Deleted this column]
*****
Change #6:
Location: All pages
Reason for Change:
Type format change to make the data entry column more visible and prominent for ease
of use.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text:
[Changed column header to read: ADD YOUR CONTENT HERE]

*****
Change #7:
Location: Page 1, Row 1
Reason for Change:
Changed because of the Jira to e-mail difference.
CY 2020 Final Rule text:
Column: Field Label
Auto *Date (no user input required)
CY 2021 Proposed Rule text:
Column: Field Label
*Date MM/DD/YYYY
*****
Change #8:
Location: Page 1, Row 1
Reason for Change:
Changed because of the Jira to e-mail difference.
CY 2020 Final Rule text:
Column: Screen Guidance
[was blank]
CY 2021 Proposed Rule text:
Column: Guidance
Change to read: “Enter the current date of submission or revision”
*****
Change #9:
Location: Page 1, Row 2
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Issue Type
CY 2021 Proposed Rule text:
Column: Field Label
* Issue Type
*****
Change #10:
Location: Page 1, Row 2
Reason for Change:
The “Question” and “Feedback” choices were not needed, so they were deleted from the
guidance.
CY 2020 Final Rule text:
Column: Screen Guidance
Select Measure Submission to nominate a measure for the 2020 MUC list. Select
Question to ask a question on the MUC process. Select Modify Candidate Measure to
change a measure already submitted for 2020. Select Feedback to leave feedback
about the 2020 MUC process.

CY 2021 Proposed Rule text:
Column: Guidance
Select Measure Submission to nominate a measure for the 2020 MUC list. Select Modify
Candidate Measure to change a measure already submitted for 2020. Select only one.
*****
Change #11:
Location: Page 1, Row 2
Reason for Change:
The “Question” and “Feedback” choices were not needed, so they were deleted from the
data entry field.
CY 2020 Final Rule text:
Column: Add Your Content Here
Measure Submission Question
Modify Candidate Measure Feedback
CY 2021 Proposed Rule text:
Column: ADD YOUR CONTENT HERE
☐ Measure Submission
☐ Modify Candidate Measure
*****
Change #12:
Location: Page 1, Row 3
Reason for Change:
Revised label because “Component” was a confusing name for this field, required in Jira.
Added asterisk to indicate a required field.
CY 2020 Final Rule text:
Column: Field Label
Component/s
CY 2021 Proposed Rule text:
Column: Field Label
*CMS Program(s)
*****
Change #13:
Location: Page 1, Row 3
Reason for Change:
Changed because of the Jira to e-mail difference.
CY 2020 Final Rule text:
Column: Screen Guidance
Start typing to get a list of possible matches or press down to select. Enter CMS
program(s) for which the measure is being submitted.
If you are submitting for MIPS, there are two choices of program. Choose MIPS-Quality
for measures that pertain to quality and/or efficiency. Choose MIPS-Cost only for
measures that pertain to cost. Do not select both MIPS-Quality and MIPS-Cost for the
same measure.

If you select MIPS (either Quality or Cost), please navigate to the Additional Resources
list at this web site: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityMeasures/Pre-Rule-Making.html, download the “MIPS
Peer Review Template and a Completed Sample,” and attach the completed form to
your JIRA submission using the “Attachments” field at the bottom of this web page.
CY 2021 Proposed Rule text:
Column: Guidance
Select the CMS program(s) for which the measure is being submitted. Select all that
apply.
If you are submitting for MIPS, there are two choices of program. Choose MIPS-Quality
for measures that pertain to quality and/or efficiency. Choose MIPS-Cost only for
measures that pertain to cost. Do not enter both MIPS-Quality and MIPS-Cost for the
same measure.
If you enter MIPS (either Quality or Cost), please navigate to the Additional Resources
list at this web site: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityMeasures/Pre-Rule-Making.html, download the “MIPS
Peer Review Template and a Completed Sample,” and send the completed form with
your template by email to [email protected].
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Change #14:
Location: Page 1, Row 3
Reason for Change:
For user convenience in selecting program name(s).
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text:
Column: Add Your Content Here
[Added check boxes to the list of all available CMS Programs]
*****
Change #15:
Location: Page 2, Row 4
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
What is the history or background for including this measure on the 2020 MUC list?
CY 2021 Proposed Rule text:
Column: Field Label
*What is the history or background for including this measure on the 2020 MUC list?

*****
Change #16:
Location: Page 2, Row 4
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select only one reason
CY 2021 Proposed Rule text:
Column: Guidance
Select only one description
*****
Change #17:
Location: Page 2, Row 4
Reason for Change:
“None” was a vestige of the Jira platform. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text:
Column: Add Your Content Here
[Deleted the choice “None” and added check boxes to the listed items]
*****
Change #18:
Location: Page 3, Row 7
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
Select as many as apply. These should be current use programs only, not programs for
the 2020 submittal.
CY 2021 Proposed Rule text
Column: Guidance
Select all that apply. These should be current use programs only, not programs for the
2020 submittal.
*****
Change #19:
Location: Page 3, Row 7
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: Add Your Content Here
[Added check boxes to the list]

*****
Change #20:
Location: Page 4, Row 8
Reason for Change:
Revised label because “Summary” was a confusing name for this field, required in Jira.
Added asterisk to indicate a required field.
CY 2020 Final Rule text:
Column: Field Label
Summary
CY 2021 Proposed Rule text
Column: Field Label
*Measure Title
*****
Change #21:
Location: Page 4, Row 8
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Provide the measure title only (255 characters or less). Put program-specific ID number
in the next field, not in the title. Note: Do not enter the NQF ID, former JIRA MUC ID
number, or any other ID numbers here (see below).
CY 2021 Proposed Rule text
Column: Guidance
Provide the measure title only (255 characters or less). Put program-specific ID number
in the next field, not in the title. Note: Do not enter the NQF ID, former JIRA MUC ID
number, or any other ID numbers here (see other fields below).
The CMS program
name should not ordinarily be part of the measure title, because each measure record
already has a required field that specifies the CMS program. An exception would be if
there are several measures with otherwise identical titles that apply to different
programs. In this case, including or imbedding a program identifier in the title (to prevent
there being any otherwise duplicate titles) is helpful.
*****
Change #22:
Location: Page 5, Row 10
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Measure description
CY 2021 Proposed Rule text
Column: Field Label
*Measure description

*****
Change #23:
Location: Page 5, Row 10
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Provide a brief description of the measure (700 characters or less).
CY 2021 Proposed Rule text
Column: Guidance
Provide a brief description of the measure (700 characters or less).
*****
Change #24:
Location: Page 5, Row 11
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Numerator
CY 2021 Proposed Rule text
Column: Field Label
*Numerator
*****
Change #25:
Location: Page 5, Row 11
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
The upper portion of a fraction used to calculate a rate, proportion, or ratio. A clinical
action to be counted as meeting a measure's requirements. For all fields, especially
Numerator and Denominator, use plain text whenever possible. If needed, convert any
special symbols, math expressions, or equations to plain text (keyboard alphanumeric,
such as + - * /). This will help reduce errors and speed up data conversion, team
evaluation, and MUC report formatting.
CY 2021 Proposed Rule text
Column: Guidance
The upper portion of a fraction used to calculate a rate, proportion, or ratio. A clinical
action to be counted as meeting a measure's requirements. For all fields, especially
Numerator and Denominator, use plain text whenever possible. If needed, convert any
special symbols, math expressions, or equations to plain text (keyboard alphanumeric,
such as + - * /). This will help reduce errors and speed up data conversion, team
evaluation, and MUC report formatting.
For all free-text fields: Be sure to spell out all abbreviations and define special terms at
their first occurrence. This will save time and revision/editing cycles during clearance.

*****
Change #26:
Location: Page 5, Row 12
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Denominator
CY 2021 Proposed Rule text
Column: Field Label
Denominator
*****
Change #27:
Location: Page 5, Row 13
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Exclusions/Exceptions
CY 2021 Proposed Rule text
Column: Field Label
* Exclusions/Exceptions
*****
Change #28:
Location: Page 5, Row 14
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Measure Type
CY 2021 Proposed Rule text
Column: Field Label
* Measure Type
*****
Change #29:
Location: Page 5, Row 14
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select only one type of measure. For definitions, visit this web site:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Pre-Rule-Making.html

CY 2021 Proposed Rule text
Column: Guidance
Select only one type of measure. For definitions, visit this web site:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Pre-Rule-Making.html
*****
Change #30:
Location: Page 5, Row 14
Reason for Change:
“None” was a vestige of the Jira platform. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Deleted the choice “None” and added check boxes to the listed items]
*****
Change #31:
Location: Page 5, Row 14
Reason for Change:
Edited the directions for “Other” for clarity, given the e-mail data collection format.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
Other (enter here):
*****
Change #32:
Location: Page 6, Row 16
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Is this measure similar to and/or competing with measure(s) already in a program?
CY 2021 Proposed Rule text
Column: Field Label
*Is this measure similar to and/or competing with measure(s) already in a program?
*****
Change #33:
Location: Page 6, Row 16
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
Consider other measures with similar purposes.

CY 2021 Proposed Rule text
Column: Guidance
Select either Yes or No. Consider other measures with similar purposes.
*****
Change #34:
Location: Page 7, Row 22
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
What is the target population of the measure?
CY 2021 Proposed Rule text
Column: Field Label
*What is the target population of the measure?
*****
Change #36:
Location: Page 7, Row 23
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
What one area of specialty is the measure aimed to, or which specialty is most likely to
report this measure?
CY 2021 Proposed Rule text
Column: Field Label
*What one area of specialty is the measure aimed to, or which specialty is most likely to
report this measure?
*****
Change #37:
Location: Page 7, Row 23
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select the most applicable area of specialty.
CY 2021 Proposed Rule text
Column: Guidance
Select the one most applicable area of specialty.
*****
Change #38:
Location: Page 7, Row 23
Reason for Change:
Editorial change for clarity

CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
See Appendix A.23 for list choices. Copy/paste or enter your choice here:
*****
Change #39:
Location: Page 8, Row 24
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
What one primary healthcare priority applies to this measure?
CY 2021 Proposed Rule text
Column: Field Label
*What one primary healthcare priority applies to this measure?
*****
Change #40:
Location: Page 8, Row 24
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Healthcare priorities (also known as domains); select the best one.
CY 2021 Proposed Rule text
Column: Guidance
Healthcare priorities (also known as domains). Select the best one.
*****
Change #41:
Location: Page 8, Row 24
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Added check boxes to the list]
*****
Change #42:
Location: Page 8, Row 25
Reason for Change:
Added asterisk symbol to indicate required field.

CY 2020 Final Rule text:
Column: Field Label
What one primary meaningful measure applies to this measure?
CY 2021 Proposed Rule text
Column: Field Label
*What one primary meaningful measure applies to this measure?
*****
Change #43:
Location: Page 8, Row 25
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Added check boxes to the list]
*****
Change #44:
Location: Page 9, Row 26
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Healthcare priorities (also known as domains); select one alternate or secondary priority
only if applicable.
CY 2021 Proposed Rule text
Column: Guidance
Healthcare priorities (also known as domains). Select one alternate or secondary priority
only if applicable.
*****
Change #45:
Location: Page 9, Row 26
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Added check boxes to the list]
*****
Change #46:
Location: Page 9, Row 27
Reason for Change:
Editorial change for clarity

CY 2020 Final Rule text:
Column: Screen Guidance
Select an alternate or secondary area only if applicable. The meaningful measure area
choices depend on your selection of secondary healthcare priority above.
CY 2021 Proposed Rule text
Column: Guidance
Select one alternate or secondary area only if applicable. The meaningful measure area
choices depend on your selection of secondary healthcare priority above.
*****
Change #47:
Location: Page 9, Row 27
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Added check boxes to the list]
*****
Change #48:
Location: Page 9, Row 28
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Briefly describe the peer reviewed evidence justifying this measure
CY 2021 Proposed Rule text
Column: Field Label
*Briefly describe the peer reviewed evidence justifying this measure
*****
Change #49:
Location: Page 9, Row 28
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
Add description of evidence.
CY 2021 Proposed Rule text
Column: Guidance
Add description of evidence. If you have lengthy text to insert, place the text at the
bottom of this form, clearly indicating row number 28.

*****
Change #50:
Location: Page 10, Row 29
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
What is the NQF status of the measure?
CY 2021 Proposed Rule text
Column: Field Label
* What is the NQF status of the measure?
*****
Change #51:
Location: Page 10, Row 29
Reason for Change:
“None” was a vestige of the Jira platform. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Deleted the choice “None” and added check boxes to the listed items]
*****
Change #52:
Location: Page 10, Row 30
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
NQF ID
CY 2021 Proposed Rule text
Column: Field Label
*NQF ID
*****
Change #53:
Location: Page 10, Row 30
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
Four- or five-digit identifier with leading zeros and following letter if needed. If no NQF ID
number is known, enter numerals 0000.
CY 2021 Proposed Rule text
Column: Guidance

Four- or five-digit identifier with leading zeros and following letter if needed. If no NQF ID
number is known, enter numerals 0000. Place zeros ahead of ID if necessary (e.g.,
0064). Add a letter after the ID if necessary (e.g., 0064e).
*****
Change #54:
Location: Page 10, Row 31
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
Provide evidence that the data source used by the measure is readily available to CMS.
Summarize how CMS would operationalize the measure. For example, if the measure is
based on registry data, the submitter must provide evidence that the majority of the
hospitals in the program in which the measure will be used participate in the registry; if
the measure is registry-based, the submitter must provide a plan for CMS to gain access
to the registry data. For eCQMs, attach feasibility scorecard or other quantitative
evidence indicating measure can be reported by the intended reporting entities.
CY 2021 Proposed Rule text
Column: Guidance
Provide evidence that the data source used by the measure is readily available to CMS.
Summarize how CMS would operationalize the measure. For example, if the measure is
based on registry data, the submitter must provide evidence that the majority of the
hospitals in the program in which the measure will be used participate in the registry; if
the measure is registry-based, the submitter must provide a plan for CMS to gain access
to the registry data. For eCQMs, attach feasibility scorecard or other quantitative
evidence indicating measure can be reported by the intended reporting entities. If you
have lengthy text to insert, place the text at the bottom of this form, clearly indicating row
number 31.
*****
Change #55:
Location: Page 11, Row 33
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
Select only one
CY 2021 Proposed Rule text
Column: Guidance
Select Yes or No
*****
Change #56
Location: Page 11, Row 34
Reason for Change:
Editorial change for clarity.

CY 2020 Final Rule text:
Column: Screen Guidance
Which specification fields are different? Select as many as apply.
CY 2021 Proposed Rule text
Column: Guidance
Which specification fields are different? Select all that apply.
*****
Change #57:
Location: Page 11, Row 34
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: Add Your Content Here
[Add check boxes to the list]
*****
Change #58:
Location: Page 11, Row 34
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Modified the choice “Other” as follows:]
☐ Other (enter here and see next field):
*****
Change #59:
Location: Page 11, Row 36
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Add check boxes to the list]
*****
Change #60:
Location: Page 12, Row 37
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here

CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Add check boxes to the list]
*****
Change #61:
Location: Page 12, Row 38
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
In what state of development is the measure?
CY 2021 Proposed Rule text
Column: Field Label
*In what state of development is the measure?
*****
Change #62:
Location: Page 12, Row 38
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select as many as apply. Hold down the Ctrl button while choosing to make multiple
selections.
CY 2021 Proposed Rule text
Column: Guidance
Select all that apply.
*****
Change #63:
Location: Page 12, Row 38
Reason for Change:
Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Add check boxes to the list]
*****
Change #64:
Location: Page 12, Row 39
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance

Details are helpful to CMS in understanding where the measure is in the developmental
cycle and will weigh heavily in determining whether or not the measure will be published
on the MUC List.
If you selected early development above, meaning testing is not currently underway,
please describe when testing is planned (i.e., specific dates), what type of testing is
planned (e.g., alpha, beta, etc.) as well as the types of facilities in which the measure will
be tested.
If you selected field testing or fully developed above, please describe what testing (e.g.,
alpha, beta, etc.) has taken place in addition to the results of that testing.
Related to testing, summarize results from validity testing including number of reporting
entities and patients measured, and how validity was assessed. Summarize results from
reliability testing including number of reporting entities and patients measured, and how
reliability was assessed.
CY 2021 Proposed Rule text
Column: Guidance
Details are helpful to CMS in understanding where the measure is in the developmental
cycle and will weigh heavily in determining whether or not the measure will be published
on the MUC List.
If you entered early development above, meaning testing is not currently underway,
please describe when testing is planned (i.e., specific dates), what type of testing is
planned (e.g., alpha, beta, etc.) as well as the types of facilities in which the measure will
be tested.
If you entered field testing or fully developed above, please describe what testing (e.g.,
alpha, beta, etc.) has taken place in addition to the results of that testing.
Related to testing, summarize results from validity testing including number of reporting
entities and patients measured, and how validity was assessed. Summarize results from
reliability testing including number of reporting entities and patients measured, and how
reliability was assessed.
*****
Change #65:
Location: Page 13, Row 40
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
In which setting was this measure tested?
CY 2021 Proposed Rule text
Column: Field Label
*In which setting was this measure tested?

*****
Change #66:
Location: Page 13, Row 40
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select as many as apply. Hold down the Ctrl button while choosing to make multiple
selections.
CY 2021 Proposed Rule text
Column: Guidance
Select all that apply.
*****
Change #67:
Location: Page 13, Row 40
Reason for Change:
“None” was a vestige of the Jira platform. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Deleted the choice “None” and added check boxes to the listed items]
*****
Change #68:
Location: Page 13, Row 40
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Modified the choice “Other” as follows:]
☐ Other (enter here):
*****
Change #69:
Location: Page 13, Row 41
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
At what level of analysis was the measure tested?
CY 2021 Proposed Rule text
Column: Field Label
*At what level of analysis was the measure tested?

*****
Change #70:
Location: Page 13, Row 41
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select all that apply
CY 2021 Proposed Rule text
Column: Guidance
Select all that apply
*****
Change #71:
Location: Page 13, Row 41
Reason for Change:
“None” was a vestige of the Jira platform. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Deleted the choice “None” and added check boxes to the listed items]
*****
Change #72:
Location: Page 13, Row 41
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
[Modified the choice “Other” as follows:]
☐ Other (enter here):
*****
Change #73:
Location: Page 13, Row 42
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
What data sources are used for the measure?
CY 2021 Proposed Rule text
Column: Field Label
*What data sources are used for the measure?

*****
Change #74:
Location: Page 14, Row 42
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select as many as apply. Hold down the Ctrl button while choosing to make multiple
selections.
If Claims, then enter relevant parts in the field below.
If EHR, then enter relevant parts in the field below.
If Registry, then enter which registry in the field below.
Use the “Comments” field to specify or elaborate on the type of data source, if needed to
define your measure.
CY 2021 Proposed Rule text
Column: Guidance
Select all that apply.
If Claims, then enter relevant parts in the field below.
If EHR, then enter relevant parts in the field below.
If Registry, then enter which registry in the field below.
Use the “Comments” field at Row 69 to specify or elaborate on the type of data source, if
needed to define your measure.
*****
Change #75:
Location: Page 14, Row 42
Reason for Change:
“None” was a vestige of the Jira platform. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
☐ Other (enter here):
*****
Change #76:
Location: Page 14, Row 44
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Identify the registry using the submitted measure. Select as many as apply. Use the
scroll bar to view all available registries.
CY 2021 Proposed Rule text
Column: Guidance

Identify the registry using the submitted measure. Select all that apply.
*****
Change #77:
Location: Page 14, Row 44
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
See Appendix A.44 for list choices. Copy/paste or enter your choices here:
*****
Change #78:
Location: Page 15, Row 45
Reason for Change:
Editorial change for clarity.
CY 2020 Final Rule text:
Column: Screen Guidance
This differs from the data sources above. This is the anticipated data submission
method. Select as many as apply. Hold down the Ctrl button while choosing to make
multiple selections. Use the “Comments” field to specify or elaborate on the type of
reporting data, if needed to define your measure.
CY 2021 Proposed Rule text
Column: Guidance
This differs from the data sources above. This is the anticipated data submission
method. Select all that apply. Use the “Comments” field at Row 69 to specify or
elaborate on the type of reporting data, if needed to define your measure.
*****
Change #79:
Location: Page 15, Row 46
Reason for Change:
Editorial change for clarity. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
☐ Other (enter here):
*****
Change #80:
Location: Page 15, Row 47
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label

Is this measure an eCQM?
CY 2021 Proposed Rule text
Column: Field Label
*Is this measure an eCQM?
*****
Change #81:
Location: Page 15, Row 47
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Is this an electronic clinical quality measure (eCQM)? Select only one. If your answer is
yes, the Measure Authoring Tool (MAT) ID number must be provided below.
CY 2021 Proposed Rule text
Column: Guidance
Is this an electronic clinical quality measure (eCQM)? Select Yes or No. If your answer is
yes, the Measure Authoring Tool (MAT) ID number must be provided below.
*****
Change #82:
Location: Page 15, Row 49
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
If eCQM, enter Measure Authoring Tool (MAT) number
CY 2021 Proposed Rule text
Column: Field Label
*If eCQM, enter Measure Authoring Tool (MAT) number
*****
Change #83:
Location: Page 15, Row 49
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
In the Attachments field below, you must attach Bonnie test cases for this measure, with
100% logic coverage (test cases should be appended), attestation that value sets are
published in Value Set Authority Center, and NQF feasibility scorecard. If not an eCQM,
or if MAT number is not available, enter 0.
CY 2021 Proposed Rule text
Column: Guidance
You must attach Bonnie test cases for this measure, with 100% logic coverage (test
cases should be appended), attestation that value sets are published in Value Set
Authority Center, and NQF feasibility scorecard. If not an eCQM, or if MAT number is not
available, enter 0.

*****
Change #84:
Location: Page 15, Row 50
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
If eCQM, does the measure have a Health Quality Measures Format (HQMF)
specification in alignment with the latest HQMF standards?
CY 2021 Proposed Rule text
Column: Field Label
*If eCQM, does the measure have a Health Quality Measures Format (HQMF)
specification in alignment with the latest HQMF standards?
*****
Change #85:
Location: Page 15, Row 50
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
If not eCQM, select No
CY 2021 Proposed Rule text
Column: Guidance
Select Yes or No. If not eCQM, enter No
*****
Change #86:
Location: Page 16, Row 51
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Evidence of performance gap
CY 2021 Proposed Rule text
Column: Field Label
*Evidence of performance gap
*****
Change #87:
Location: Page 16, Row 51
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Evidence of a performance gap among the units of analysis in which the measure will be
implemented. Provide analytic evidence that the units of analysis have room for
improvement and, therefore, that the implementation of the measure would be
meaningful. The distribution of performance should be wide. Measures must not address

“topped-out” opportunities. Please provide current rate of performance and standard
deviation from that rate to demonstrate variability. If available, please provide information
on the testing data set. If available, include percent average performance rate, minimum,
and maximum. Include validity and reliability values in a standard format, and the
population size used in determining these values.
CY 2021 Proposed Rule text
Column: Guidance
Evidence of a performance gap among the units of analysis in which the measure will be
implemented. Provide analytic evidence that the units of analysis have room for
improvement and, therefore, that the implementation of the measure would be
meaningful. The distribution of performance should be wide. Measures must not address
“topped-out” opportunities. Please provide current rate of performance and standard
deviation from that rate to demonstrate variability. If available, please provide information
on the testing data set. If available, include percent average performance rate, minimum,
and maximum. Include validity and reliability values in a standard format, and the
population size used in determining these values. If you have lengthy text to insert, place
the text at the bottom of this form, clearly indicating row number 51.
*****
Change #88:
Location: Page 16, Row 53
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Was this measure published on a previous year's Measures under Consideration list?
CY 2021 Proposed Rule text
Column: Field Label
*Was this measure published on a previous year's Measures under Consideration list?
*****
Change #89:
Location: Page 16, Row 53
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
If yes, you are submitting an existing measure for expansion into additional CMS
programs or the measure has substantially changed since originally published, then
proceed to the following subset of data fields including: In what prior year(s) was this
measure published?, What were the MUC IDs for the measure in each year?, Why was
the measure not recommended by the MAP workgroups in those year(s)?, What were
the programs that NQF MAP reviewed the measure for in each year?, List the NQF MAP
workgroup(s) in each year, What was the NQF MAP recommendation each year?, and
NQF MAP report page number being referenced for each year. If no, then skip these
subset questions.
CY 2021 Proposed Rule text
Column: Guidance

Select Yes or No. If yes, you are submitting an existing measure for expansion into
additional CMS programs or the measure has substantially changed since originally
published, then answer the following questions: 54 through 59 and 61. If no, then skip
these subset questions.
*****
Change #90:
Location: Page 17, Row 54
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select as many as apply. Hold down the Ctrl button while choosing to make multiple
selections.
CY 2021 Proposed Rule text
Column: Guidance
Select all that apply.
*****
Change #91:
Location: Page 17, Row 54
Reason for Change:
Editorial change for clarity. Boxes added for user convenience.
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
☐ Other (enter here):
*****
Change #92:
Location: Page 18, Row 60
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
[was blank]
CY 2021 Proposed Rule text
Column: Guidance
See reference link information at right.
*****
Change #93:
Location: Page 18, Row 60
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Add Your Content Here

CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
For your reference in completing this section, follow the links below or copy/paste the
links into your browser to view each year's MAP pre-rulemaking report (2012 to 2019).
This is not a data entry field.
2016-19: http://www.qualityforum.org/map/
2015: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78711
2014: http://www.qualityforum.org/Publications/2014/01/MAP_PreRulemaking_Report__2014_Recommendations_on_Measures_for_More_than_20_Fede
ral_Programs.aspx
2013: http://www.qualityforum.org/Publications/2013/02/MAP_PreRulemaking_Report_-_February_2013.aspx
2012: http://www.qualityforum.org/Publications/2012/02/MAP_PreRulemaking_Report__Input_on_Measures_Under_Consideration_by_HHS_for_2012_R
ulemaking.aspx
All major NQF reports going back to 2008 should be locatable here:
http://www.qualityforum.org/Publications.aspx
*****
Change #94:
Location: Page 19, Row 63
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Measure steward
CY 2021 Proposed Rule text
Column: Field Label
*Measure steward
*****
Change #95:
Location: Page 19, Row 63
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Select the current Measure Steward. Select as many as apply. Use the scroll bar to view
all available stewards. Hold down the Ctrl button while choosing to make multiple
selections.
CY 2021 Proposed Rule text
Column: Guidance
Enter the current Measure Steward. Select all that apply.

*****
Change #96:
Location: Page 19, Row 63
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Add Your Content Here
CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
See Appendix A.63-65 for list choices. Copy/paste or enter your choices here:
*****
Change #97:
Location: Page 19, Row 64
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Measure Steward Contact Information
CY 2021 Proposed Rule text
Column: Field Label
*Measure Steward Contact Information
*****
Change #98:
Location: Page 19, Row 65
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
Entity or entities that will be the permanent measure steward(s), responsible for
maintaining the measure and conducting NQF maintenance review. Use the scroll bar to
view all available stewards. Hold down the Ctrl button while choosing to make multiple
selections.
CY 2021 Proposed Rule text
Column: Guidance
Entity or entities that will be the permanent measure steward(s), responsible for
maintaining the measure and conducting NQF maintenance review. Select all that apply.
*****
Change #99:
Location: Page 19, Row 65
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Add Your Content Here

CY 2021 Proposed Rule text
Column: ADD YOUR CONTENT HERE
See Appendix A.63-65 for list choices. Copy/paste or enter your choices here:
*****
Change #101:
Location: Page 20, Row 67
Reason for Change:
Added asterisk symbol to indicate required field.
CY 2020 Final Rule text:
Column: Field Label
Primary Submitter Contact Information
CY 2021 Proposed Rule text
Column: Field Label
*Primary Submitter Contact Information
*****
Change #102:
Location: Page 20, Row 70
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
The maximum file upload size is 10.00 MB. You are encouraged to attach measure
information form (MIF) if available. This is a detailed description of the measure used by
NQF during endorsement proceedings. If a MIF is not available, comprehensive
measure methodology documents are encouraged.
If you select MIPS, please navigate to the Additional Resources list at this web site:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Pre-Rule-Making.html, download the “MIPS Peer Review
Template and a Completed Sample,” and attach the completed form to your JIRA
submission using the “Attachments” field at the bottom of this web page.
If eCQM, you must attach Bonnie test cases for this measure, with 100% logic coverage
(test cases should be appended), attestation that value sets are published in Value Set
Authority Center, and NQF feasibility scorecard.
CY 2021 Proposed Rule text
Column: Guidance
You are encouraged to attach the measure information form (MIF) if available. This is a
detailed description of the measure used by NQF during endorsement proceedings. If a
MIF is not available, comprehensive measure methodology documents are encouraged.
If you enter MIPS, please navigate to the Additional Resources list at this web site:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Pre-Rule-Making.html, download the “MIPS Peer Review
Template and a Completed Sample,” and send the completed form with your measure
submission by email to [email protected]

If eCQM, you must attach Bonnie test cases for this measure, with 100% logic coverage
(test cases should be appended), attestation that value sets are published in Value Set
Authority Center, and NQF feasibility scorecard.
*****
Change #103:
Location: Page 21, Row 71
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Column: Screen Guidance
For those submitting measures to MIPS program, click “Yes” after you have attached
your completed Peer Reviewed Journal Article Requirement form.
CY 2021 Proposed Rule text
Column: Guidance
Select Yes or No. For those submitting measures to MIPS program, enter “Yes.” Send
your completed Peer Reviewed Journal Article Requirement form with your measure
submission by email to [email protected].
*****
Change #104:
Location: Page 21, bottom
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
[was blank]
CY 2021 Proposed Rule text
Send any questions or your completed form and any accompanying files to
[email protected]
*****
Change #105:
Location: Page 22, A-23
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
A.23 Choices for what area of specialty best fits the measure?
CY 2021 Proposed Rule text
A.23 Choices for What area of specialty best fits the measure?
*****
Change #106:
Location: Page 22, A-23
Reason for Change:
“None” was a vestige of the Jira platform.
CY 2020 Final Rule text:
“None”

CY 2021 Proposed Rule text
[Deleted “None” from the list of choices.]
*****
Change #107:
Location: Page 22, A-23
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Not applicable
CY 2021 Proposed Rule text
Other (enter in Row 23)
*****
Change #108:
Location: Page 23, A-44
Reason for Change:
Editorial change for readability
CY 2020 Final Rule text:
Not applicable
CY 2021 Proposed Rule text
[Sorted the list of registries so that all entries are in alphabetical order.]
*****
Change #109:
Location: Page 23, A-44
Reason for Change:
Edited one list entry for clarity and added new list entry at CMS request.
CY 2020 Final Rule text:
Geriatric Practice Management LTC Registry
CY 2021 Proposed Rule text
Geriatric Practice Management LTC Qualified Clinical Data Registry
Geriatric Practice Management LTC Registry
*****
Change #110:
Location: Page 26, A63-65
Reason for Change:
“None” was a vestige of the Jira platform.
CY 2020 Final Rule text:
Not applicable
CY 2021 Proposed Rule text
[Deleted “None” from the list of choices.]

*****
Change #111:
Location: Page 26, A63-65
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
Not applicable
CY 2021 Proposed Rule text
Other (enter in Row 63 or Row 65)
*****
Change #112:
Location: Page 28
Reason for Change:
Editorial change for clarity
CY 2020 Final Rule text:
[was blank]
CY 2021 Proposed Rule text
Space for Placing Lengthy Text (If Applicable)
If you have lengthy text to insert, place it below here, clearly indicating for each answer
the intended row number and/or field label from the template above.
Send any questions or your completed form and any accompanying files to
[email protected]