Appendix E1 Measures under Consideration 2022 (for the 2024 performa

Centers for Medicare & Medicaid Services Measures Under Consideration 2022 Data Template for Candidate Measures

Instructions:

1. Before accessing the CMS MERIT (Measures Under Consideration Entry/Review and Information Tool) online system, you are invited to 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.

3. For each row, the “Guidance” column provides details on how to complete the template and what kinds of data to include. Unless otherwise specified the character limit for text fields in CMS MERIT is 8000 characteristics.

4. 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.”

5. Numeric fields are noted, where applicable, in the “Add Your Content Here” column.

6. Note that CMS MERIT does not accommodate text formatting, including nested tables, carriage returns, and indented bulleted lists.

7. Row numbers are for convenience only and do not appear on the CMS MERIT user interface.

8. Send any questions to [email protected].

PROPERTIES

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	001	*Measure Title	Provide the measure title only (255 characters or less). Put any program-specific identification (ID) number under Characteristics, not in the title. Note: Do not enter the CMIT ID, consensus-based entity (endorsement) 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 name in the title (to prevent there being any otherwise duplicate titles) is helpful. For additional information on measure title, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf	ADD YOUR CONTENT HERE
Measure Information	002	*Measure description	Provide a brief description of the measure (700 characters or less). For additional information on measure description, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf	ADD YOUR CONTENT HERE
Measure Information	003	*Select the CMS program(s) for which the measure is being submitted.	Select all that apply. Please note, measures specified and intended for use at more than one level of analysis must be submitted separately for each level of analysis (e.g., individual clinician, facility). If you choose multiple programs for this submission, please ensure the programs fall under the same level of analysis. If you choose multiple programs and need guidance as to whether your selection represents multiple levels of analysis, please contact [email protected]. There is functionality within CMS MERIT to decrease the data entry process for multiple submissions of the same measure. Please reach out to [email protected] for guidance and support. If you are submitting for MIPS, there are two choices of program. Do NOT enter both MIPS-Quality and MIPS-Cost for the same measure. Choose MIPS-Quality for measures that pertain to quality and/or efficiency. Choose MIPS-Cost only for measures that pertain to cost. Because you selected MIPS, you are required to download the MIPS Peer Reviewed Journal Article Template and attach the completed form to your submission using the “Attachments” page.	☐ Ambulatory Surgical Center Quality Reporting Program ☐ End-Stage Renal Disease (ESRD) Quality Incentive Program ☐ Home Health Quality Reporting Program ☐ Hospice Quality Reporting Program ☐ Hospital-Acquired Condition Reduction Program ☐ Hospital Inpatient Quality Reporting Program ☐ Hospital Outpatient Quality Reporting Program ☐ Hospital Readmissions Reduction Program ☐ Hospital Value-Based Purchasing Program ☐ Inpatient Psychiatric Facility Quality Reporting Program ☐ Inpatient Rehabilitation Facility Quality Reporting Program ☐ Long-Term Care (LTC) Hospital Quality Reporting Program ☐ Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs) ☐ Medicare Shared Savings Program ☐ Merit-based Incentive Payment System-Cost ☐ Merit-based Incentive Payment System-Quality ☐ Part C and D Star Ratings [Medicare] ☐ Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program ☐ Skilled Nursing Facility Quality Reporting Program ☐ Skilled Nursing Facility Value-Based Purchasing Program
n/a	n/a	If you select “Merit-based Incentive Payment System -Quality” in Row 003, then Row 004 becomes an optional field.	n/a	This is not a data entry field.
Measure Information	004	MIPS Quality: Identify any links with related Cost measures and Improvement Activities	For MIPS Quality measures only: Where available, provide description of linkages and a rationale that correlates this MIPS quality measure to other performance category measures and activities.	ADD YOUR CONTENT HERE
Measure Information	005	*State of Development	Select one. Note that fully developed measures are highly preferred. See the definition of fully developed measure within CMS MERIT for guidance. For additional information regarding state of development, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf	☐ Conceptualization ☐ Specification ☐ Field (Beta) Testing ☐ Fully Developed
n/a	n/a	If you select “Conceptualization,” “Specification”, or “Field (Beta) Testing” in Row 005, then Row 006 becomes a required field. If you select “Fully Developed” in Row 005, then skip to Row 007.	n/a	This is not a data entry field.
Measure Information	006	*State of Development Details	If “Conceptualization,” “Specification,” or “Field (Beta) Testing,” describe when testing is planned (i.e., specific dates), what type of testing is planned (e.g., alpha, beta) as well as the types of facilities in which the measure will be tested. For additional information, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf	ADD YOUR CONTENT HERE
Measure Information	007	*Level of Analysis	Select the level of analysis at which the measure is specified and intended for use. If the measure is specified and intended for use at more than one level, submit the others separately. Any testing results provided in subsequent sections of this submission must be conducted at the level of analysis selected here. For MIPS submissions, you must report the results of individual clinician-level testing. If group-level testing is available, you may submit those results as an attachment.	☐ Clinician - Individual ☐ Clinician - Group ☐ Facility ☐ Health plan ☐ Medicaid program (e.g., Health Home or 1115) ☐ State ☐ Other (enter here):
Measure Information	008	*In which setting(s) was this measure tested?	Select all that apply.	☐ Ambulatory surgery center ☐ Ambulatory/office-based care ☐ Behavioral health clinic ☐ Inpatient psychiatric facility ☐ Community hospital ☐ Dialysis facility ☐ Emergency department ☐ Federally qualified health center (FQHC) ☐ Hospital outpatient department (HOD) ☐ Home health ☐ Hospice ☐ Hospital inpatient acute care facility ☐ Inpatient rehabilitation facility ☐ Long-term care hospital ☐ Nursing home ☐ PPS-exempt cancer hospital ☐ Skilled nursing facility ☐ Veterans Health Administration facility ☐ Not yet tested ☐ Other (enter here):
Measure Information	009	*Multiple Scores	Does the submitter recommend that more than one measure score be reported for this measure (e.g., 7- and 30-day rate, rates for different procedure types, etc.)? If yes, describe the different scores and rationale for reporting both. Note: If “Yes”, indicate which score will be described in this form. Submit separate attachments for each of the other scores.	☐ Yes (enter here): ☐ No
Measure Information	010	*Numerator	The upper portion of a fraction used to calculate a rate, proportion, or ratio. An 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.	ADD YOUR CONTENT HERE
Measure Information	011	*Numerator Exclusions	For additional information on exclusions/exceptions, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf. If not applicable, enter ‘N/A.’	ADD YOUR CONTENT HERE
Measure Information	012	*Denominator	The lower part of a fraction used to calculate a rate, proportion, or ratio. The denominator is associated with a given population that may be counted as eligible to meet a measure’s inclusion requirements.	ADD YOUR CONTENT HERE
Measure Information	013	*Denominator Exclusions	For additional information on exclusions/exceptions, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf. If not applicable, enter ‘N/A.’	ADD YOUR CONTENT HERE
Measure Information	014	*Denominator Exceptions	For additional information on exclusions/exceptions, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf. If not applicable, enter ‘N/A.’	ADD YOUR CONTENT HERE

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Implementation	015	*Feasibility of Data Elements	Select the extent to which the specified data elements are available in electronic fields. Select all that apply. For a PRO-PM, select the data collection format(s). Electronic fields should include a designated location and format for the data in claims, EHRs, registries, etc.	☐ ALL data elements are in defined fields in electronic sources ☐ Some data elements are in defined fields in electronic sources ☐ No data elements are in defined fields in electronic sources
Measure Implementation	016	*Feasibility Assessment	Summarize how you evaluated the feasibility of the data elements included in your measure. For claims-based measures, indicate whether the codes included in the measure appear in the claims used to calculate the measure (e.g., if based on Medicare claims, does Medicare cover the services included in the measure?). For electronic clinical quality measures (eCQMs), attach the feasibility scorecard and other quantitative evidence (if available) indicating that the data required to calculate the measure can be feasibly obtained from the data source. For registry-based or other third-party measures, describe what testing was done to evaluate the feasibility of transferring the data between provider and the third-party. For manually abstracted measures, discuss whether abstractors were able to consistently locate the information required for the measure in the medical records	ADD YOUR CONTENT HERE
Measure Implementation	017	*Method of measure calculation	Select the method used to calculate measure scores. If the measure can be calculated two or more ways, select all that apply (e.g., measure is fully specified as an eCQM for providers with EHRs and fully specified for manual abstraction for providers without an EHR). Please review guidance before making selections. Select “Claims” if the measure can be calculated entirely from claims data submitted for billing or other purposes. If the measure requires supplemental data codes to be submitted with claims (e.g., MIPS measures that require Part B quality data codes), select “Hybrid.” Select “eCQM" if the measure is specified entirely using accepted national standards for eCQMs (https://ecqi.healthit.gov/ecqm-standards). If the measure only uses some eCQM data elements (e.g., clinical eCQM data is merged with claims data), select “Hybrid.” Select “Other digital method” if the measure is not specified using accepted national standards for eCQMs but can be calculated electronically (e.g., registry, MDS, OASIS). If data needs to be manually abstracted prior to measure calculation (e.g., provider inputs data into registry or online portal manually), select “Hybrid.” Select “Manual abstraction” if all data elements in the measure require manual review of records prior to measure calculation.	☐ Claims ☐ eCQM ☐ Other digital method ☐ Manual abstraction ☐ Hybrid ☐ Other (enter here):
Measure Implementation	n/a	If you select “Hybrid” in Row 017, then Row 018 becomes an optional field.	n/a	This is not a data entry field.
Measure Implementation	018	Hybrid measure: Methods of calculation	Select all methods that apply	☐ Claims ☐ eCQM ☐ Other digital method ☐ Manual abstraction
Measure Implementation	019	*How is the measure expected to be reported to the program?	This is the anticipated data submission method. Select all that apply. Use the ”Submitter Comments” field to specify or elaborate on the type of reporting data, if needed to define your measure.	☐ eCQM ☐ Clinical Quality Measure (CQM) Registry ☐ Claims ☐ Web interface ☐ Other (enter here):
Measure Implementation	020	*Stratification	Does the submitter recommend that measure scores be stratified (e.g., by provider characteristics, by patient characteristics)? If “Yes”, describe the different strata and recommended method for stratifying the results. Note whether overall results will be reported in addition to stratified results. Note: If “Yes”, include the stratified results as an attachment	☐ Yes (enter here): ☐ No

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Burden	021	*Burden for Provider: Was a provider workflow analysis conducted?	Select one	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 021, then Row 022 and 023 become required fields. If you select “No” in Row 022, then skip to Row 024.	n/a	This is not a data entry field.
Burden	022	*If yes, how many sites were evaluated in the provider workflow analysis?	Enter the number of sites that were evaluated in the provider workflow analysis.	Numeric field
Burden	023	*Did the provider workflow have to be modified to accommodate the new measure?	Select one	☐ Yes ☐ No

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	024	*Reliability	Indicate whether reliability testing was conducted for the accountable entity-level measure scores. For more information on accountable entity level reliability testing, refer to the CMS Measures Management System Blueprint (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf) Note: This section refers to the reliability of the accountable entity level measure scores in the final performance measure. Refer to the Patient-Reported Data section for testing of surveys or patient reported tools. Note: for MIPS submissions, please provide individual clinician-level results. If the measure was also tested at the clinician group level, you may include those results in an attachment.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 024, then Row 025 becomes a required field. If you select “No” in Row 024, then skip to Row 038.	n/a	This is not a data entry field.
Measure Score Level (Accountable Entity Level) Testing	025	*Reliability: Type of analysis	Select all that apply. Signal-to-noise (or inter-unit reliability) is the precision attributed to an actual construct versus random variation (e.g., ratio of between unit variance to total variance) (Adams J. The reliability of provider profiling: a tutorial. Santa Monica, CA: RAND; 2009. http://www.rand.org/pubs/technical_reports/TR653.html). Random split-half correlation is the agreement between two measures of the same concept derived from split samples drawn from the same entity at a single point in time.	☐ Signal-to-Noise ☐ Random Split-Half Correlation ☐ Other (enter here):
n/a	n/a	If you select “Signal-to-Noise,” in Row 025, then Rows 026-029 become required fields. If you select, “Random Split-Half Correlation,” in Row 025, then Rows 030-033 become required fields. If you select “Other” in Row 025, then Rows 034-037 become required fields.	n/a	This is not a data entry field.
Measure Score Level (Accountable Entity Level) Testing	026	*Signal-to-Noise: Name of statistic	Enter specific name of analysis that was conducted, as applicable.	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	027	*Signal-to-Noise: Sample size	Indicate the number of accountable entities sampled to test the final performance measure.	Numeric field
Measure Score Level (Accountable Entity Level) Testing	028	*Signal-to-Noise: Statistical result	Indicate the median result for the signal-to-noise analysis used to assess accountable entity level reliability. Results should range from 0.00 to 1.00. Calculate reliability as the measure is intended to be implemented (e.g., after applying minimum denominator requirements, appropriate type of setting, provider, etc.).	Numeric field
Measure Score Level (Accountable Entity Level) Testing	029	*Signal-to-Noise: Interpretation of results	Describe the interpretation of the results (e.g., low, moderate, high). List accepted thresholds referenced and provide a citation. If applicable, include the precision of the statistical result (e.g., 95% confidence interval) and/or an assessment of statistical significance (e.g., p-value)	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	030	*Random Split-Half Correlation: Name of statistic	Enter specific name of analysis that was conducted, as applicable.	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	031	*Random Split-Half Correlation: Sample size	Indicate the number of accountable entities sampled to test the final performance measure. If number varied by sample, use the largest number of measured entities.	Numeric field
Measure Score Level (Accountability Entity Level) Testing	032	*Random Split-Half Correlation: Statistical result	Indicate the statistical result for the random split-half correlation analysis used to assess accountable entity level reliability. Results should range from -1.00 to 1.00. Calculate reliability as the measure is intended to be implemented (e.g., after applying minimum denominator requirements, appropriate type of setting, provider, etc.).	Numeric field
Measure Score Level (Accountability Entity Level) Testing	033	*Random Split-Half Correlation: Interpretation of results	Describe the interpretation of the results (e.g., low, moderate, high). List accepted thresholds referenced and provide a citation. If applicable, include the precision of the statistical result (e.g., 95% confidence interval) and/or an assessment of statistical significance (e.g., p-value).	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	034	*Other: Name of statistic	Enter specific name of statistic.	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	035	*Other: Sample size	Indicate the number of accountable entities sampled to test the final performance measure.	Numeric field
Measure Score Level (Accountability Entity Level) Testing	036	*Other: Statistical result	Indicate the statistical result for the analysis used to assess accountable entity level reliability. Calculate reliability as the measure is intended to be implemented (e.g., after applying minimum denominator requirements, appropriate type of setting, provider, etc.).	Numeric field
Measure Score Level (Accountability Entity Level) Testing	037	*Other: Interpretation of results	Describe the interpretation of the results (e.g., low, moderate, high). List accepted thresholds referenced and provide a citation. If applicable, include the precision of the statistical result (e.g., 95% confidence interval) and/or an assessment of statistical significance (e.g., p-value).	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	038	*Empiric Validity	Indicate whether empiric validity testing was conducted for the accountable entity-level measure scores. For more information on accountable entity level empiric validity testing, refer to the CMS Measures Management System Blueprint (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf) Note: This section refers to the empiric validity of the accountable entity level measure scores in the final performance measure. Refer to the Patient-Reported Data section for testing of surveys or patient reported tools. Note: for MIPS submissions, please provide individual clinician-level results. If the measure was also tested at the clinician group level, you may include those results in an attachment.	☐ Yes ☐ No
n/a	n/a	If you select “Yes,” in Row 038, then Rows 039-043 become required fields. If you select “No” in Row 038, then skip to Row 044.	n/a	This is not a data entry field.
Measure Score Level (Accountability Entity Level) Testing	039	*Empiric Validity: Statistic name	Indicate the name for the statistic used to assess accountable entity level validity. Describe whether the result is a relative risk, odds ratio, relative difference in scores, etc. If more than one test or comparison was conducted, describe the statistic that most strongly supported the validity of the measure and provide the full testing results under the “Methods and findings” question or as an attachment.	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	040	* Empiric Validity: Sample size	Indicate the number of accountable entities sampled to test the final performance measure.	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	041	*Empiric Validity: Statistical result	Indicate the statistical result. Calculate empiric validity as the measure is intended to be implemented (e.g., after applying minimum denominator requirements, etc.). If more than one test or comparison was conducted, provide the result that most strongly supports the validity of the measure and provide the full testing results under the “Methods and findings” question or as an attachment.	Numeric field
Measure Score Level (Accountability Entity Level) Testing	042	*Empiric Validity: Methods and findings	Describe the methods used to assess accountable entity level validity. Describe the comparison groups or constructs used to verify the validity of the measure scores, including hypothesized relationships (e.g., expected to be positively or negatively correlated). Describe your findings for each analysis conducted, including the statistical result provided above and the strongest and weakest results across analyses. If applicable, include the precision of the statistical result(s) (e.g., 95% confidence interval) and/or an assessment of statistical significance (e.g., p-value). If methods and results require more space, include as an attachment.	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	043	*Empiric Validity: Interpretation of results	Indicate whether the statistical result affirmed the hypothesized relationship for the analysis conducted.	☐ Yes ☐ No
Measure Score Level (Accountable Entity Level) Testing	044	*Face validity	Indicate if a vote was conducted among experts and patients/caregivers on whether the final performance measure scores can be used to differentiate good from poor quality of care. Select “No” if experts and patients/caregivers did not provide feedback on the final performance measure at the specified level of analysis or if the feedback was related to a property of the measure unrelated to its ability to differentiate performance among measured entities.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 044, then Rows 045-046 become required fields. If you select “No” in Row 044, then skip to Row 047.	n/a	This is not a data entry field.
Measure Score Level (Accountable Entity Level) Testing	045	*Face validity: Number of voting experts and patients/caregivers	Indicate the number of experts and patients/caregivers who voted on face validity.	Numeric field
Measure Score Level (Accountable Entity Level) Testing	046	*Face validity: Result	Indicate the number of experts and patients/caregivers who voted in agreement that the measure could differentiate good from poor quality care among accountable entities. If votes were conducted using a scale, sum all responses in agreement with the statement. Do not include neutral votes. If more than one question was asked of the experts and patients/caregivers, only provide results from the question relating to the ability of the final performance measure to differentiate good from poor quality care.	Numeric field

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	047	*Patient/Encounter Level Testing	Indicate whether patient/encounter level testing of the individual data elements in the final performance measure was conducted. Select “No” if testing was not conducted for each critical data element required to identify the denominator and numerator. If testing was conducted for a subset of critical data elements only, select “No” and submit these results as an attachment. Note: This section includes tests of both data element reliability and validity. Note: for MIPS submissions, please provide individual clinician-level results. If the measure was also tested at the clinician group level, you may include those results in an attachment.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 047, then Rows 048-052become required fields. If you select “No” in Row 047 then skip to Row 053.	n/a	This is not a data entry field.
Patient/Encounter Level (Data Element Level) Testing	048	*Type of Analysis	Select all that apply. For more information on patient/encounter level testing, refer to the CMS Measures Management System Blueprint (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf) Note: This section refers to the patient/encounter level data elements in the final performance measure. Refer to the Patient-Reported Data section for testing of patient/encounter level data elements in surveys or patient reported tools.	☐ Agreement between two manual reviewers ☐ Agreement between eCQM and manual reviewer ☐ Agreement between other gold standard and manual reviewer ☐ Other (enter here):
Patient/Encounter Level (Data Element Level) Testing	049	*Sample Size	Indicate the number of patients/encounters sampled.	Numeric field
Patient/Encounter Level (Data Element Level) Testing	050	*Statistic Name	Indicate the statistic used to assess agreement (e.g., percent agreement, kappa, positive predictive value, etc.). If more than one type of statistic was calculated, list the one that best depicts the reliability and/or validity of the data elements in your measure.	☐ Percent agreement ☐ Kappa ☐ ICC ☐ Pearson correlation coefficient ☐ Sensitivity ☐ Positive Predictive Value ☐ Other (enter here):
Patient/Encounter Level (Data Element Level) Testing	051	*Statistical Results	Indicate the lowest critical data element result of the statistic selected above.	Numeric field
Patient/Encounter Level (Data Element Level) Testing	052	*Interpretation of results	Briefly describe the interpretation of results including summary results for the overall denominator (with inclusion, exclusion, and exception criteria) and numerator. Include 95% confidence intervals for the overall denominator and numerator results, as applicable. If any data element has low reliability or validity, describe the anticipated impact and whether it could introduce bias to measure scores. If there is variation in reliability or validity scores across test sites/measured entities, describe how this variation impacts overall interpretation of the results. Include a list of all data elements tested that includes their frequency, statistical results, and 95% confidence intervals, as applicable. Provide results broken down by test site if reliability/validity varied between sites. If more room is needed, include as an attachment.	ADD YOUR CONTENT HERE

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient-Reported Data	053	*Does the performance measure use survey or patient-reported data?	Indicate whether the performance measure utilizes data from structured surveys or patient-reported tools.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 053, then Rows 054-059 become required fields. If you select “No” in Row 053, then skip to Row 062.	n/a	This is not a data entry field.
Patient-Reported Data	054	*Surveys or patient-reported outcome tools	List each survey or patient-reported outcome tool accepted by the performance measure and indicate whether the tool(s) have been validated by a peer reviewed study or empirical testing. Indicate whether the tool(s) are being used as originally specified and tested or if modifications are required. If available provide each survey or tool as a link or attachment. Describe the mode(s) of administration available (e.g., electronic, phone, mail) and the number of languages the survey(s) or tool(s) are available in. Indicate whether any of the surveys or tools is proprietary requiring licenses or fees for use.	ADD YOUR CONTENT HERE
Patient-Reported Data	055	*Meaningful to Patients: Number consulted	Indicate the number of patients and/or caregiver representatives who provided feedback on whether the survey or tool meaningfully informs the care they receive and/or helps them better understand their condition or treatment. If the measure uses an established survey or tool, include information from the original development of the survey or tool. If the measure uses a modified version of the survey or applies the survey to a new patient population, it is recommended to obtain patient feedback on the survey as it would be used for the purposes of the performance measure. If the measure allows for the use of more than one survey or tool, include the number of patients consulted on the most relevant or primary survey or tool in this field and provide feedback on the other tools as an attachment.	Numeric field
Patient-Reported Data	056	*Meaningful to Patients: Number indicating survey/tool is meaningful	Indicate the number of patients and/or caregiver representatives who agreed the survey or tool meaningfully informs the care they receive and/or helps them better understand their condition or treatment. If the measure allows for the use of more than one survey or tool, include patient feedback on the most relevant or primary survey or tool in this field and provide feedback on the other tools as an attachment.	Numeric field
Patient-Reported Data	057	*Meaningful to Clinicians: Number consulted	Indicate the number of clinicians who provided feedback on whether the survey or tool meaningfully informs the care they provide their patients. If the measure uses an established survey or tool, include information from the original development of the survey or tool. If the measure uses a modified version of the survey or applies the survey to a new patient population, it is recommended to obtain clinician feedback on the survey as it would be used for the purposes of the performance measure. If the measure allows for the use of more than one survey or tool, include the number of clinicians consulted on the most relevant or primary survey or tool in this field and provide feedback on the other tools as an attachment.	Numeric field
Patient-Reported Data	058	*Meaningful to Clinicians: Number indicating survey/tool is meaningful	Indicate the number of clinicians who agreed that the survey or tool meaningfully informs the care they provide their patients. If the measure allows for the use of more than one survey or tool, include the number of clinicians consulted on the most relevant or primary survey or tool in this field and provide feedback on the other tools as an attachment.	Numeric field
Patient-Reported Data	059	*Survey level testing	Indicate whether survey level testing was conducted. For a list of acceptable types of testing, please refer to the latest CMS Blueprint version (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf). Select “yes” if you can provide relevant testing of the survey or tool conducted either prior to development of the performance measure or as part of the development of the performance measure.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 059, then Rows 060-061 become required fields. If you select “No” in Row 059, then skip to Row 062.	n/a	This is not a data entry field.
Patient-Reported Data	060	*Type of testing analysis	Select all that apply.	☐ Internal Consistency ☐ Construct Validity ☐ Other (enter here):
Patient-Reported Data	061	*Testing methodology and results	Briefly describe the method used to psychometrically test or validate the patient survey or patient-reported outcome tool. (e.g., Cronbach’s alpha, ICC, Pearson correlation coefficient, Kuder-Richardson test). If the survey or tool was developed prior to the development of the performance measure, describe how the intended use of the survey or tools for the performance measure aligns with the survey or tool as originally designed and tested. Indicate whether the measure uses all components within a tool, or only parts of the tool. Summarize the statistical results and briefly describe the interpretation of results.	ADD YOUR CONTENT HERE

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	062	*Measure performance - type of score	Select one	☐ Proportion ☐ Ratio ☐ Continuous Variable – Mean ☐ Continuous Variable – Median ☐ Other (enter here):
Measure Performance	063	*Measure performance score interpretation	Select one	☐ Higher score is better ☐ Lower score is better ☐ Score falling within a defined interval ☐ Passing score ☐ Never event ☐ Other (enter here):
Measure Performance	064	*Mean performance score	Provide the mean performance score across accountable entities in the test sample that is relevant to the intended use of the measure. Note: for MIPS submissions, please provide individual clinician-level results. If the measure was also tested at the clinician group level, you may include those results in an attachment.	Numeric field
Measure Performance	065	*Median performance score	Provide the median performance score for the testing sample that is relevant to the intended use of the measure.	Numeric field
Measure Performance	066	*Minimum performance score	Provide the minimum performance score for the testing sample that is relevant to the intended use of the measure.	Numeric field
Measure Performance	067	*Maximum performance score	Provide the maximum performance score for the testing sample that is relevant to the intended use of the measure.	Numeric field
Measure Performance	068	*Standard deviation of performance scores	Provide the standard deviation of performance scores for the testing sample that is relevant to the intended use of the measure.	Numeric field

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Impact	069	* Meaningful to Patients. Was input on the final performance measure collected from patient and/or caregiver?	Select one	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 068, then Rows 069-070 become required fields. If you select “No” in Row 068, then skip to Row 071.	n/a	This is not a data entry field.
Impact	070	*Total number of patients and/or caregivers who responded to the question asking them whether the final performance measure helps inform care and decision making	Indicate number	Numeric field
Impact	071	*Total number of patients/caregivers who agreed that the final performance measure information helps inform care and decision making	Indicate number using the total number of patients who responded.	Numeric field
Impact	072	*Meaningful to Clinicians. Were clinicians and/or providers consulted on the final performance measure?	Select one	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 072, then Rows 073-074 become required fields. If you select “No” in Row 072, then skip to Row 075.	n/a	This is not a data entry field.
Impact	073	*Total number of clinicians/providers who responded when asked if the final performance measure was actionable to improve quality of care	Indicate number	Numeric field
Impact	074	*Total number of clinicians/providers who agreed that the final performance measure was actionable to improve quality of care	Indicate the total number who responded. This is separate from any face validity testing conducted.	Numeric field
Impact	075	*Estimated impact of the measure: Estimate of annual denominator size	Enter the numerical value of the estimated annual denominator size across accountable entities eligible to report the measure. This can be estimated from the average entity-level denominator in the test sample multiplied by the approximate number of eligible entities that may report the measure. If the measure requires a multi-year denominator, divide the estimate to report the estimated number of denominator cases per year rather than for the full denominator period. If it is not possible to estimate based on the testing sample and other publicly available information, enter 0000.	Numeric field

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Cost Factors	076	Cost estimate completed	Indicate whether an estimate of the impact on healthcare costs was completed as part of the business case or development process.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 076, then Row 077 becomes an optional field.	n/a	This is not a data entry field.
Cost Factors	077	Cost estimate methods and results	Briefly describe the methods and assumptions for your cost estimates and cite the sources of cost information. Provide the year of the cost estimate (e.g., 2016 dollars). If adjusted for inflation, provide the year the estimate was adjusted to (e.g., 2020 dollars after adjusting for inflation). Summarize the range of healthcare cost impacts based on your analysis.	ADD YOUR CONTENT HERE

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Background Information	078	*What is the history or background for including this measure on the current year MUC List?	Select one	☐ New measure never previously submitted to the MUC List, reviewed by Measure Applications Partnership (MAP) Workgroup, or used in a CMS program ☐Measure previously submitted but not included on the MUC List ☐ Measure previously submitted to MAP, refined and resubmitted per MAP recommendation ☐ Measure currently used in a CMS program being submitted as-is for a new or different program ☐ Measure currently used in a CMS program, but the measure is undergoing substantial change
n/a	n/a	If you select “New measure never previously submitted to the MUC List, reviewed by Measure Applications Partnership (MAP) Workgroup, or used in a CMS Program” in Row 078 then skip to Row 081. If you select “Measure currently used in a CMS program being submitted as-is for a new or different program” or Measure currently used in a CMS program, but the measure is undergoing substantial change” then Rows 079-080 become required fields.	n/a	This is not a data entry field.
Background Information	079	*Range of year(s) this measure has been used by CMS Program(s).	For example: Hospice Quality Reporting (2012-2018)	ADD YOUR CONTENT HERE
Background Information	080	*What other federal programs are currently using this measure?	Select all that apply. These should be current use programs only, not programs for the upcoming year’s submittal.	☐ Ambulatory Surgical Center Quality Reporting Program ☐ End-Stage Renal Disease Quality Incentive Program ☐ Home Health Quality Reporting Program ☐ Hospice Quality Reporting Program ☐ Hospital-Acquired Condition Reduction Program ☐ Hospital Inpatient Quality Reporting Program ☐ Hospital Outpatient Quality Reporting Program ☐ Hospital Readmissions Reduction Program ☐ Hospital Value-Based Purchasing Program ☐ Inpatient Psychiatric Facility Quality Reporting Program ☐ Inpatient Rehabilitation Facility Quality Reporting Program ☐ Long-Term Care Hospital Quality Reporting Program ☐ Medicare and Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals (CAHs) ☐ Medicare Shared Savings Program ☐ Merit-based Incentive Payment System ☐ Part C and D Star Ratings [Medicare] ☐ Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program ☐ Quality Health Plan Quality Rating System ☐ Skilled Nursing Facility Quality Reporting Program ☐ Skilled Nursing Facility Value-Based Purchasing Program ☐ Other (enter here):

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Data Sources	081	*What data sources are used for the measure?	Select all that apply. Use the next field to specify or elaborate on the type of data source, if needed to define your measure.	☐ Administrative Data (non-claims) ☐ Claims Data ☐ Electronic Clinical Data (non-EHR) ☐ Electronic Health Record ☐ Paper Medical Records ☐ Standardized Patient Assessments ☐ Patient Reported Data and Surveys ☐ Registries ☐ Other (enter here):
Data Sources	082	If applicable, specify the data source	Use this field to specify or elaborate on the type of data source, if needed, to define your measure.	ADD YOUR CONTENT HERE
Data Sources	083	Description of parts related to each data source	Describe the parts or elements of the measure that are relevant to the selected data sources	ADD YOUR CONTENT HERE

STEWARD

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Steward Information	084	*Measure Steward	Enter the current Measure Steward.	See Appendix A.084-086 for list choices. Copy/paste or enter your choices here:
Steward Information	085	*Measure Steward Contact Information	Please provide the contact information of the measure steward.	ADD YOUR CONTENT HERE
Long-Term Steward Information	086	Long-Term Measure Steward (if different)	Entity or entities that will be the permanent measure steward(s), responsible for maintaining the measure and conducting CBE endorsement maintenance review. Select all that apply.	See Appendix A. 084-086 for list choices. Copy/paste or enter your choices here:
Long-Term Steward Information	087	Long-Term Measure Steward Contact Information	If different from Steward above: Last name, First name; Affiliation; Telephone number; Email address.	ADD YOUR CONTENT HERE
Submitter Information	088	Is primary submitter the same as steward?	Select “Yes” or “No.”	☐ Yes ☐ No
Submitter Information	089	*Primary Submitter Contact Information	If different from Steward above: Last name, First name; Affiliation; Telephone number; Email address. NOTE: The primary and secondary submitters entered here do not automatically have read/write/change access to modify this measure in CMS MERIT. To request such access for others, when logged into the CMS MERIT interface, navigate to “About” and “Contact Us,” and indicate the name and e-mail address of the person(s) to be added.	ADD YOUR CONTENT HERE
Submitter Information	090	Secondary Submitter Contact Information	If different from name(s) above: Last name, First name; Affiliation; Telephone number; Email address.	ADD YOUR CONTENT HERE

CHARACTERISTICS

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
General Characteristics	091	*Measure Type	Select only one type of measure. For definitions, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf.	☐ Cost/Resource Use ☐ Efficiency ☐ Intermediate Outcome ☐ Outcome ☐ Outcome - (PRO-PM) ☐ Process ☐ Structure ☐ Other (enter here):
n/a	n/a	If you select “Outcome” or “Outcome – (PRO-PM)" in Row 091 then Row 121 in the Evidence section becomes a required field. Continue to complete required General Characteristics and Evidence questions.	n/a	This is not a data entry field.
General Characteristics	092	*Is the measure a composite or component of a composite?	Select one	☐ Composite measure ☐ Component of a composite measure ☐ Not a composite or component of a composite measure
General Characteristics	093	*Is this measure in the CMS Measures Inventory Tool (CMIT)?	Select Yes or No. Current measures can be found at https://cmit.cms.gov/CMIT_public/ListMeasures	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 093 then Row 094becomes a required field.	n/a	This is not a data entry field.
General Characteristics	094	*CMIT ID	If the measure is currently in CMIT, enter the CMIT ID in the format #####-X-XXXXXXX. Current measures and CMIT IDs can be found at https://cmit.cms.gov/CMIT_public/ListMeasures	ADD YOUR CONTENT HERE
General Characteristics	095	Alternate Measure ID	DO NOT enter consensus-based entity (endorsement) ID, CMIT ID, or previous year MUC ID in this field. This is an alphanumeric identifier (if applicable), such as a recognized program ID number for this measure (20 characters or less). Examples: 199 GPRO HF-5; ACO 28; CTM-3; PQI #08.	ADD YOUR CONTENT HERE
General Characteristics	096	*What is the target population of the measure?	What populations are included in this measure? e.g., Medicare Fee for Service, Medicare Advantage, Medicaid, Children’s Health Insurance Program (CHIP), All Payer, etc.	ADD YOUR CONTENT HERE
General Characteristics	097	*What one area of specialty the measure is aimed to, or which specialty is most likely to report this measure?	Select one.	See Appendix A.097 for list choices. Copy/paste or enter your choice(s) here:
General Characteristics	098	*Evidence of performance gap	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. If you have lengthy text add the evidence as an attachment, named to clearly indicate the related form field.	ADD YOUR CONTENT HERE
General Characteristics	099	*Unintended consequences	Summary of potential unintended consequences if the measure is implemented. Information can be taken from the CMS consensus-based entity Consensus Development Process (CDP) manuscripts or documents. If referencing CDP documents, you must submit the document or a link to the document, and the page being referenced.	ADD YOUR CONTENT HERE

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Evidence	100	*Type of evidence to support the measure	Select all that apply. Refer to the latest CMS Blueprint version (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf) and the supplementary material related to evidence review (https://www.cms.gov/files/document/blueprint-environmental-scans.pdf) to obtain updated guidance.	☐ Clinical Guidelines or USPSTF (U.S. Preventive Services Task Force) Guidelines ☐ Peer-Reviewed Systematic Review ☐ Empirical data ☐ Other (enter here):
n/a	n/a	If you select “Clinical Guidelines or USPSTF (U.S. Preventive Services Task Force) Guidelines in Row 100, then Rows 101-102 become required fields. If you select “Systematic Review” in Row 100, then Rows 115-116 become required fields. If you select “Empirical data” in Row 100, then Rows 117-118 become required fields. If you select “Other” in Row 100, then Rows 119-120 become required fields.	n/a	This is not a data entry field.
Evidence	101	*Number of clinical guidelines, including USPSTF guidelines that address this topic	Enter a numerical value of ≥1. Count all guidelines that are relevant to this measure topic including those that offer contradictory guidance.	Numeric field
Evidence	102	*Outline the clinical guideline(s) supporting this measure	Provide a detailed description of which guideline(s) support the measure and indicate for each, whether they are evidence-based or consensus-based. Summarize the meaning/rationale of the guideline statements that are being referenced, their relation to the measure concept and how they support the measure whether directly or indirectly, and how the guideline statement(s) relate to the measure’s intended accountable entity. Describe the body of evidence that supports the statement(s) by describing the quantity, quality and consistency of the studies that are pertinent to the guideline statements/sentence. Quantity of studies represent the number of studies and not the number of publications associated with a study. If the statement is advised by 3 publications reporting outcomes from the same RCT at 3 different time points, this is considered a single study and not 3 studies. If referencing a standard norm which may or may not be driven by evidence, provide the description and rationale for this norm or threshold as reasoned by the guideline panel. If this is an outcome measure or PRO-PM, indicate how the evidence supports or demonstrates a link between at least one process, structure, or intervention and the outcome. Document the criteria used to assess the quality of the clinical guidelines such as those proposed by the Institute of Medicine or ECRI Guideline’s Trust (see CMS Blueprint version (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf and the supplementary material related to evidence review. (https://www.cms.gov/files/document/blueprint-environmental-scans.pdf) If there is lengthy text, describe the guidelines in an evidence attachment, named to clearly indicate the related form field.	ADD YOUR CONTENT HERE
Evidence	103	*Name the guideline developer/entity	If the response to the Number of clinical guidelines, including USPSTF guidelines, that address this measure topic is >1, identify the guideline that most closely aligns with and supports your measure concept. This is now referred to as the primary clinical guideline. Spell out the primary clinical guideline entity’s name followed by the appropriate acronym, if available. For example: United States Preventive Services Task Force (USPSTF)	ADD YOUR CONTENT HERE
Evidence	104	*Publication year	Provide the publication year for the primary clinical guideline. Use the 4-digit format (e.g., 2016).	Numeric field (4-digit year)
Evidence	105	*Full citation +/- URL	Provide the full citation for the primary clinical guideline in any established citation style (e.g., AMA, APA, Chicago, Vancouver, etc.) and the accompanying URL, if available.	ADD YOUR CONTENT HERE
Evidence	106	*Is this an evidence-based clinical guideline	There are disparate methods of developing clinical guidance documents. An evidence-based guideline is one which uses evidence to inform the development of their recommendations. The evidence must be reviewed in a deliberate, systematic manner. To determine this, the developer must have provided a description of a systematic search of literature and their search strategy which includes the dates of the literature covered, databases consulted, and a screening, review and data extraction process. Select “No” for clinical guidelines that are based purely on expert consensus with or without supplementation with a narrative literature review (non-systematic).	☐ Yes ☐ No
Evidence	107	*Is the guideline graded?	A graded guideline is one which explicitly provides evidence rating and recommendation grading conventions in the document itself. Grades are usually found next to each recommendation statement. Select one.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 107, then Rows 108-113 become required fields. If you select “No” in Row 107, then skip to Row 114.	n/a	This is not a data entry field.
Evidence	108	*List the guideline statement that most closely aligns with the measure concept.	If there are more than one statement from this clinical guideline that may be relevant to this measure concept, document the statement that most closely aligns with the measure concept as it is written in the guideline document. For example, Statement 1: In patients aged 65 years and older who have prediabetes, we recommend a lifestyle program similar to the Diabetes Prevention Program to delay progression to diabetes. No more than one statement should be written in the text box. All other relevant statements should be submitted in a separate evidence attachment.	ADD YOUR CONTENT HERE
Evidence	109	*What evidence grading system did the guideline use to describe strength of recommendation?	Select the evidence grading system used by the clinical guideline. (e.g., GRADE or USPSTF) to describe the guideline statement’s strength of recommendation.	☐ GRADE method ☐ Modified GRADE ☐ USPSTF ☐ Other (enter here)
Evidence	110	*List all categories and corresponding definitions for the evidence grading system used to describe strength of recommendation in the guideline?	Insert the complete list of grading categories and their definitions.	ADD YOUR CONTENT HERE
Evidence	111	*For the guideline statement that most closely aligns with the measure concept, what is the associated strength of recommendation?	Select the associated strength of recommendation using the convention used by the guideline developer. Select one.	☐ USPSTF Grade A, Strong recommendation or similar ☐ USPSTF Grade B or D, Moderate recommendation or similar ☐ USPSTF Grade C or I, Conditional/weak recommendation or similar ☐ Expert Opinion ☐ Other (enter here)
Evidence	112	*List all categories and corresponding definitions for the evidence grading system used to describe level of evidence or level of certainty in the evidence?	Insert the complete list of grading categories and their definitions.	ADD YOUR CONTENT HERE
Evidence	113	*For the guideline statement that most closely aligns with the measure concept, what is the associated level of evidence or level of certainty in the evidence?	Select the associated level of evidence or certainty of evidence using the convention used by the guideline developer. Select one.	☐ High or similar ☐ Moderate or similar ☐ Low, Very Low or similar ☐ Other (enter here)
Evidence	114	*List the guideline statement that most closely aligns with the measure concept.	If there are more than one statement from this clinical guideline that may be relevant to this measure concept, document the statement that most closely aligns with the measure concept as it is written in the guideline document. For example, Statement 1: In patients aged 65 years and older who have prediabetes, we recommend a lifestyle program similar to the Diabetes Prevention Program to delay progression to diabetes. No more than one statement should be written in the text box. All other relevant statements should be submitted in a separate evidence attachment.	ADD YOUR CONTENT HERE
Evidence	115	*Number of systematic reviews that inform this measure concept	Insert the number of peer reviewed systematic reviews that addresses this measure topic. This includes systematic reviews that address the same intervention/ process/ structure but may have conflicting conclusions. Enter a numerical value of greater than or equal to 1.	Numeric field
Evidence	116	*Briefly summarize the peer-reviewed systematic review(s) that inform this measure concept	Summarize the peer-reviewed systematic review(s) that address this measure concept. For each systematic review, provide the number of studies within the systematic review that addressed the specifics defined in this measure concept, indicate whether a study-specific risk of bias/quality assessment was performed for each study, and describe the consistency of findings. Number of studies is not equivalent to the number of publications. If there are three publications from a single cohort study cited in the systematic review, report one when indicating the number of studies. For every systematic review cited, provide full citations using any established citation style. If this is an outcome measure or PRO-PM, indicate how the evidence supports or demonstrates a link between at least one process, structure, or intervention with the outcome. If there is lengthy text, submit details via an evidence attachment.	ADD YOUR CONTENT HERE
Evidence	117	*Source of empirical data	Select all that apply	☐ Published, peer-reviewed original research ☐ Published and publicly available reports (e.g., from agencies) ☐ Internal data analysis ☐ Other (enter here)
Evidence	118	*Summarize the empirical data	Provide a summary of the empirical data and how it informs this measure concept. Describe the limitations of the data and provide a full citation for each source of empirical data in any established citation style. If this is an outcome measure or PRO-PM, indicate how the evidence supports or demonstrates a link between at least one process, structure, or intervention with the outcome. If there is lengthy text, include details in a separate evidence attachment.	ADD YOUR CONTENT HERE
Evidence	119	*Name evidence type	If citing evidence other than clinical guidelines, peer-reviewed systematic reviews and empirical data, state the type of evidence referenced to inform this measure concept.	ADD YOUR CONTENT HERE
Evidence	120	*Summarize the evidence	Provide a summary of the other type(s) of evidence used to inform this measure concept. Describe the limitations of the data and provide a full citation for piece of evidence cited in any established citation style. If this is an outcome measure or PRO-PM, indicate how the evidence supports or demonstrates a link between at least one process, structure, or intervention with the outcome. If there is lengthy text, include details in a separate evidence attachment.	ADD YOUR CONTENT HERE
Evidence	121	*Does the evidence discuss a link between at least one process, structure, or intervention with the outcome?	Select “Yes” if the evidence that was discussed in the evidence section demonstrate a link between at least one process, structure, or intervention with the outcome.	☐ Yes ☐ No

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment	122	*Is the measure risk adjusted?	Select one.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 122, then Rows 123-124 become required fields and you should not answer Row 125. If you select “Yes” in Row 122 you are also encouraged to upload documentation about your risk adjustment model as an attachment. If you select “No” in Row 122, then skip to Row 125.	n/a	This is not a data entry field.
Risk Adjustment	123	*Risk adjustment variables	Select ALL risk adjustment variable types that are included in your final risk model. For more information on how to select risk factors for accountability measures, refer to the CMS Measures Management System Blueprint (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf Select “Patient-level demographics” if the measure uses information related to each patient’s age, sex, race/ethnicity, etc. Select “Patient-level health status & clinical conditions” if the measure uses information specific to each individual patient about their health status prior to the start of care (e.g., case-mix adjustment). Select “Patient functional status” if the measure uses information specific to each individual patient’s functional status prior to the start of care (e.g., body function, ability to perform activities of daily living, etc.) Select “Patient-level social risk factors” if the measure uses patient-reported information related to their individual social risks (e.g., income, living alone, etc.) Select “Proxy social risk factors” if the measure uses data related to characteristics of the people in the patient’s community (e.g., neighborhood level income from the census) Select “Patient community characteristic” if the measure uses information about the patient’s community (e.g., percent of vacant houses, crime rate). Select “Other” if the risk factor is related to the healthcare provider, health system, or other factor that is not related to the patient.	☐ Patient-level demographics ☐ Patient-level health status & clinical conditions ☐ Patient functional status ☐ Patient-level social risk factors ☐ Proxy social risk factors ☐ Patient community characteristics ☐ Other (enter here):
Risk Adjustment	n/a	If you select “Patient Demographics” in Row 123, then Row 124 becomes a required field. If you select “Patient-level health status & clinical conditions” in Row 123, then Row 125 becomes a required field. If you select “Patient functional status” in Row 123, then Row 126 becomes a required field. If you select “Patient-level social risk factors” in Row 123, then Row 127 becomes a required field. If you select “Proxy social risk factors” in Row 123, then Row 128 becomes a required field. If you select “Patient community characteristics” in Row 123, then Row 129 becomes a required field.	n/a	This is not a data entry field.
Risk Adjustment	124	*Patient-level demographics: please select all that apply	Select all that apply	☐ Age ☐ Sex ☐ Gender ☐ Race/ethnicity ☐ Other (enter here):
Risk Adjustment	125	*Patient-level health status & clinical conditions: please select all that apply	Select all that apply	☐ Case-Mix Adjustment ☐ Severity Illness ☐ Health behaviors/health choices ☐ Other (enter here):
Risk Adjustment	126	*Patient functional status: please select all that apply	Select all that apply	☐ Body Function ☐ Ability to perform activities of daily living ☐ Other (enter here):
Risk Adjustment	127	*Patient-level social risk factors: please select all that apply	Select all that apply	☐ Income ☐ Education ☐ Wealth ☐ Living Alone ☐ Social Support ☐ Other (enter here):
Risk Adjustment	128	*Proxy social risk factors: please select all that apply	Select all that apply	☐ Neighborhood Level Income from the Census ☐ Dual Eligibility for Medicare and Medicaid ☐ Other (enter here):
Risk Adjustment	129	*Patient community characteristics: please select all that apply	Select all that apply	☐ Percent of Vacant Houses ☐ Crime Rate ☐ Urban/Rural ☐ Other (enter here):
Risk Adjustment	130	*Risk model performance	Provide empirical evidence that the risk model adequately accounts for confounding factors (e.g., c-statistics). Describe your interpretation of the results.	ADD YOUR CONTENT HERE
Risk Adjustment	131	*Rationale for not using risk adjustment	Select ALL reasons for not implementing a risk adjustment model in the measure. For more information on measure types that do not require risk adjustment, refer to the CMS Measures Management System Blueprint (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf	☐ Addressed through exclusions (e.g., process measures) ☐ Addressed through stratification of results ☐ Not conceptually or empirically indicated (enter here): ☐ Other (enter here):

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Healthcare Domain	132	*What one healthcare domain applies to this measure?	Select the ONE most applicable healthcare domain. For more information, see: https://www.cms.gov/meaningful-measures-20-moving-measure-reduction-modernization	☐ Person-Centered Care ☐ Equity ☐ Safety ☐ Affordability and Efficiency ☐ Chronic Conditions ☐ Wellness and Prevention ☐ Seamless Care Coordination ☐ Behavioral Health

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Endorsement Characteristics	133	*What is the endorsement status of the measure?	Select only one. For information on consensus-based entity (CMS contractor) endorsement, measure ID, and other information, refer to: http://www.qualityforum.org/QPS/	☐ Endorsed ☐ Endorsement removed ☐ Submitted ☐ Failed endorsement ☐ Never submitted
Endorsement Characteristics	134	*CBE ID (CMS consensus-based entity, or endorsement ID)	Four- or five-character identifier with leading zeros and following letter if needed. Add a letter after the ID (e.g., 0064e) and place zeros ahead of ID if necessary (e.g., 0064). If no CBE ID number is known, enter numerals 9999.	ADD YOUR CONTENT HERE
Endorsement Characteristics	135	If endorsed: Is the measure being submitted exactly as endorsed by the CMS CBE?	Select 'Yes' or 'No'. Note that 'Yes' should only be selected if the submission is an EXACT match to the CBE-endorsed measure.	☐ Yes ☐ No
n/a	n/a	If you select “No” in Row 135, then Rows 136-137 become required fields.	n/a	This is not a data entry field.
Endorsement Characteristics	136	If not exactly as endorsed, specify the locations of the differences	Indicate which specification fields are different. Select all that apply.	☐ Measure title ☐ Description ☐ Numerator ☐ Denominator ☐ Exclusions ☐ Target population ☐ Setting (for testing) ☐ Level of analysis ☐ Data source ☐ eCQM status ☐ Other (enter here and see next field):
Endorsement Characteristics	137	If not exactly as endorsed, describe the nature of the differences	Briefly describe the differences	ADD YOUR CONTENT HERE
Endorsement Characteristics	138	If endorsed: Year of most recent CDP endorsement	Select one	☐ None ☐ 2018 ☐ 2019 ☐ 2020 ☐ 2021 ☐ 2022
Endorsement Characteristics	139	Year of next anticipated CDP endorsement review	Select one. If you are submitting for initial endorsement, select the anticipated year.	☐ None ☐ 2022 ☐ 2023 ☐ 2024 ☐ 2025 ☐ 2026

GROUPS

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	140	*Is this measure 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. For more information on eCQMs, see: https://www.emeasuretool.cms.gov/	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 140, then Rows 141-143 become required fields. If you select “No” in Row 140, then skip to Row 144.	n/a	This is not a data entry field.
n/a	141	* Measure Authoring Tool (MAT) Number	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 (VSAC), and feasibility scorecard. If not an eCQM, or if MAT number is not available, enter 0.	ADD YOUR CONTENT HERE
n/a	142	* If eCQM, does the measure have a Health Quality Measures Format (HQMF) specification in alignment with the latest HQMF and eCQM standards, and does the measure align with Clinical Quality Language (CQL) and Quality Data Model (QDM)?	Select 'Yes' or 'No'. For additional information on HQMF standards, see: https://ecqi.healthit.gov/tool/hqmf	☐ Yes ☐ No
n/a	143	* If eCQM, does any electronic health record (EHR) system tested need to be modified?	Select “Yes” if any of the EHR systems tested had to modify how data were entered by providers or stored to facilitate calculation of the eCQM. Select “No” if the data needed to calculate the eCQM were already included in structured fields in the EHR systems tested and none of them needed to be modified.	☐ Yes ☐ No

SIMILAR MEASURES

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Similar In-Use Measures	144	*Is this measure similar to and/or competing with measure(s) already in a program?	Select either Yes or No. Consider other measures with similar purposes.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 144 then Rows 145-147 become required fields. If you select “No” in Row 137, then skip to Row 148.	n/a	This is not a data entry field.
Similar In-Use Measures	145	If Yes: Which measure(s) already in a program is your measure similar to and/or competing with?	Identify the other measure(s) including title and any other unique identifier.	ADD YOUR CONTENT HERE
Similar In-Use Measures	146	If Yes: How will this measure add value to the CMS program?	Describe benefits of this measure, in comparison to measure(s) already in a program.	ADD YOUR CONTENT HERE
Similar In-Use Measures	147	If Yes: How will this measure be distinguished from other similar and/or competing measures?	Describe key differences that set this measure apart from others.	ADD YOUR CONTENT HERE

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Previous Measures	148	*Was this measure published on a previous year's Measures Under Consideration List?	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.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 147 then Rows 148-148 become required fields. If you select “No” in Row 147, then skip to Row 155.	n/a	This is not a data entry field.
Previous Measures	149	*In what prior year(s) was this measure published?	Select all that apply. NOTE: If your measure was published on more than one prior annual MUC List, as you use the MERIT interface, click “Add Another Measure” and complete the information section for each of those years.	☐ None ☐ 2012 ☐ 2013 ☐ 2014 ☐ 2015 ☐ 2016 ☐ 2017 ☐ 2018 ☐ 2019 ☐ 2020 ☐ 2021 ☐ Other (enter here):
Previous Measures	150	*What were the MUC IDs for the measure in each year?	List both the year and the associated MUC ID number in each year. If unknown, enter N/A.	ADD YOUR CONTENT HERE
Previous Measures	151	*List the CMS CBE MAP workgroup(s) in each year	List both the year and the associated workgroup name in each year. Workgroup options: Clinician; Hospital; Post-Acute Care/Long-Term Care; Coordinating Committee. Example: "Clinician, 2014."	ADD YOUR CONTENT HERE
Previous Measures	152	*What were the programs that MAP reviewed the measure for in each year?	List both the year and the associated program name in each year.	ADD YOUR CONTENT HERE
Previous Measures	153	*What was the MAP recommendation in each year?	List the year(s), the program(s), and the associated recommendation(s) in each year. Options: Support; Do Not Support; Conditionally Support; Refine and Resubmit.	ADD YOUR CONTENT HERE
Previous Measures	154	*Why was the measure not recommended by the MAP workgroups in those year(s)?	Briefly describe the reason(s) if known.	ADD YOUR CONTENT HERE
Previous Measures	155	*MAP report page number being referenced for each year	List both the year and the associated MAP report page number for each year.	ADD YOUR CONTENT HERE
Previous Measures	156	*If this measure is being submitted to meet a statutory requirement, list the corresponding statute	List title and other identifying citation information.	ADD YOUR CONTENT HERE

ATTACHMENTS

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
N/A	157	Attachment(s)	You are encouraged to attach the measure information form (MIF) if available. This is a detailed description of the measure used by the CMS consensus-based entity (CBE) during endorsement proceedings. If a MIF is not available, comprehensive measure methodology documents are encouraged. If you are submitting for MIPS (either Quality or Cost), you are required to download the MIPS Peer Reviewed Journal Article Template and attach the completed form to your submission using the “Attachments” feature. See https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Pre-Rulemaking If your measure is risk adjusted, you are encouraged to attach documentation that provides additional detail about the measure risk adjustment model such as variables included, associated code system codes, and risk adjustment model coefficients If eCQM, you must attach MAT Output/HQMF, Bonnie test cases for this measure, with 100% logic coverage (test cases should be appended), attestation that value sets are published in VSAC, and feasibility scorecard.	ADD YOUR CONTENT HERE
N/A	158	MIPS Peer Reviewed Journal Article Template	Select Yes or No. For those submitting measures to MIPS program, enter “Yes.” Attach your completed Peer Reviewed Journal Article Template.	☐ Yes ☐ No

COMMENTS

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
N/A	159	Submitter Comments	Any notes, qualifiers, external references, or other information not specified above.	ADD YOUR CONTENT HERE

Send any questions to [email protected]

Appendix: Lengthy Lists of Choices

A. 084-086 Choices for Measure Steward (084) and Long-Term Measure Steward (if different) (086)

Agency for Healthcare Research & Quality

Alliance of Dedicated Cancer Centers

Ambulatory Surgical Center (ASC) Quality Collaboration

American Academy of Allergy, Asthma & Immunology (AAAAI)

American Academy of Dermatology

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Otolaryngology – Head and Neck Surgery (AAOHN)

American College of Cardiology

American College of Cardiology/American Heart Association

American College of Emergency Physicians

American College of Emergency Physicians (previous steward Partners-Brigham & Women's)

American College of Obstetricians and Gynecologists (ACOG)

American College of Radiology

American College of Rheumatology

American College of Surgeons

American Gastroenterological Association

American Health Care Association

American Medical Association

American Nurses Association

American Psychological Association

American Society for Gastrointestinal Endoscopy

American Society for Radiation Oncology

American Society of Addiction Medicine

American Society of Anesthesiologists

American Society of Clinical Oncology

American Society of Clinical Oncology

American Urogynecologic Society

American Urological Association (AUA)

Audiology Quality Consortium/American Speech-Language-Hearing Association (AQC/ASHA)

Bridges to Excellence

Centers for Disease Control and Prevention

Centers for Medicare & Medicaid Services

Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC

Health Resources and Services Administration (HRSA) - HIV/AIDS Bureau

Heart Rhythm Society (HRS)

Indian Health Service

Infectious Diseases Society of America (IDSA)

Intersocietal Accreditation Commission (IAC)

KCQA- Kidney Care Quality Alliance

Minnesota (MN) Community Measurement

National Committee for Quality Assurance

National Minority Quality Forum

Office of the National Coordinator for Health Information Technology/Centers for Medicare & Medicaid Services

Oregon Urology Institute

Oregon Urology Institute in collaboration with Large Urology Group Practice Association

Pharmacy Quality Alliance

Philip R. Lee Institute for Health Policy Studies

Primary (care) Practice Research Network (PPRNet) 

RAND Corporation

Renal Physicians Association; joint copyright with American Medical Association -

Seattle Cancer Care Alliance

Society of Gynecologic Oncology

Society of Interventional Radiology

The Academy of Nutrition and Dietetics

The Joint Commission

The Society for Vascular Surgery

The University of Texas MD Anderson Cancer Center

University of Minnesota Rural Health Research Center

University of North Carolina- Chapel Hill

Wisconsin Collaborative for Healthcare Quality (WCHQ)

Other (enter in Row 084 and/or Row 086)

A.097 Choices for Areas of specialty (097)

Addiction medicine

Allergy/immunology

Anesthesiology

Behavioral health

Cardiac electrophysiology

Cardiac surgery

Cardiovascular disease (cardiology)

Chiropractic medicine

Colorectal surgery (proctology)

Critical care medicine (intensivists)

Dermatology

Diagnostic radiology

Electrophysiology

Emergency medicine

Endocrinology

Family practice

Gastroenterology

General practice

General surgery

Geriatric medicine

Gynecological oncology

Hand surgery

Hematology/oncology

Hospice and palliative care

Infectious disease

Internal medicine

Interventional pain management

Interventional radiology

Maxillofacial surgery

Medical oncology

Nephrology

Neurology

Neuropsychiatry

Neurosurgery

Nuclear medicine

Nursing

Nursing homes

Obstetrics/gynecology

Occupational therapy

Ophthalmology

Optometry

Oral surgery (dentists only)

Orthopedic surgery

Osteopathic manipulative medicine

Otolaryngology

Pain management

Palliative care

Pathology

Pediatric medicine

Peripheral vascular disease

Physical medicine and rehabilitation

Physical therapy

Plastic and reconstructive surgery

Podiatry

Preventive medicine

Primary care

Psychiatry

Public and/or population health

Pulmonary disease

Pulmonology

Radiation oncology

Rheumatology

Sleep medicine

Speech therapy

Sports medicine

Surgical oncology

Thoracic surgery

Urology

Vascular surgery
Other (enter in Row 097)

Send any questions to [email protected]

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2022 CMS MUC LIST DATA TEMPLATE 23 3/01/2022