Crosswalk - Appendix E2: Measures under Consideration 2023 Data Template for Candidate Measures

MUC Data Template Crosswalk

CY 2022 Final Versus CY 2023 Final

Burden Impact: The changes to this form do not reflect policies in the CY 2024 Physician Fee Scheduled (PFS) Notice of Proposed Rulemaking (NPRM) for the Quality Payment Program. There are no impacts to burden as a result of any changes reflected in this crosswalk.

Change #1

Location: Title (Page 1)

Reason for Change: Updated to reflect MERIT

CY 2022 Final Rule text: Measures under Consideration 2022 Data Template for Candidate Measures

CY 2023 Final Rule text: Measures Under Consideration Entry/Review and Information Tool 2023 Data Template for Candidate Measures

Change #2

Location: Instructions (Page 1)

Reason for Change: Updated instructions for clarity.

CY 2022 Final Rule text:

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].

CY 2023 Final Rule text:

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 unless otherwise indicated in the template.

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 characters.

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

7. Send any questions to [email protected].

Change #3

Location: Page 1, Measure Information, Row 001, Guidance column

Reason for Change: Updated to current website.

CY 2022 Final Rule text: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf

CY 2023 Final Rule text: https://mmshub.cms.gov/measure-lifecycle/measure-specification/document-measure.

Change #4

Location: Page 1, Measure Information, Row 002, Guidance column

Reason for Change: Updated to current website.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Provide a brief description of the measure. For additional information on measure description, see: https://mmshub.cms.gov/measure-lifecycle/measure-specification/document-measure.

Change #5

Location: Page 2, Measure Information, Row 003, Guidance column

Reason for Change: This information was relocated to a different section.

CY 2022 Final Rule text: 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.

CY 2023 Final Rule text: N/A

Change #6

Location: Page 2, Measure Information, Row 003, ADD YOUR CONTENT HERE column

Reason for Change: Updated to current CMS program titles.

CY 2022 Final Rule text:

☐ 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

CY 2023 Final Rule text:

☐ Ambulatory Surgical Center Quality Reporting Program

☐ End-Stage Renal Disease (ESRD) Quality Incentive Program

☐ Home Health Quality Reporting Program

☐ Hospice Quality Reporting Program

☐ Hospital Inpatient Quality Reporting Program

☐ Hospital Outpatient Quality Reporting Program

☐ Hospital Readmissions Reduction Program

☐ Hospital Value-Based Purchasing Program

☐ Hospital-Acquired Condition Reduction Program

☐ Inpatient Psychiatric Facility Quality Reporting Program

☐ Inpatient Rehabilitation Facility Quality Reporting Program

☐ Long-Term Care (LTC) Hospital Quality Reporting Program

☐ Medicare 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 & D Star Ratings [Medicare]

☐ Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program

☐ Rural Emergency Hospital Quality Reporting Program

☐ Skilled Nursing Facility Quality Reporting Program

☐ Skilled Nursing Facility Value-Based Purchasing Program

Change #7

Location: Page 2, Measure Information, Row 004, Guidance column

Reason for Change: Updated language to remove redundant language.

CY 2022 Final Rule text: 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.

CY 2023 Final Rule text: Where available, provide description of linkages and a rationale that correlates this MIPS quality measure to other performance category measures and activities.

Change #8

Location: Page 3, Measure Information, Row 005, Field Label column

Reason for Change: Updated language for clarity.

CY 2022 Final Rule text: *State of Development

CY 2023 Final Rule text: *Stage of Development

Change #9

Location: Page 3, Measure Information, Row 005, Guidance column

Reason for Change: Updated language for clarity and updated to current website.

CY 2022 Final Rule text: 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

CY 2023 Final Rule text: Select the measure’s current stage of development. A fully developed measure is a measure that has completed beta testing. Note that fully developed measures are highly preferred.

For additional information regarding stage of development, see: https://mmshub.cms.gov/blueprint-measure-lifecycle-overview.

Change #10

Location: Page 3, Measure Information, Row 006, Field Label column

Reason for Change: Updated language for clarity.

CY 2022 Final Rule text: *State of Development

CY 2023 Final Rule text: *Stage of Development

Change #11

Location: Page 3, Measure Information, Row 006, Guidance column

Reason for Change: Updated to current website.

CY 2022 Final Rule text: For additional information, see: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf

CY 2023 Final Rule text: For additional information, see: https://mmshub.cms.gov/blueprint-measure-lifecycle-overview.

Change #12

Location: Page 4, Measure Information, Row 007, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Language updated for clarity of MIPS measure testing requirements and level of analysis.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	007	*Level of Analysis	Select one. 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 other levels separately. Any testing results provided in subsequent sections of this submission must be conducted at the level of analysis selected here. For submission to the MIPS-Quality program, you must report, at minimum, the results of individual clinician-level testing. If testing is performed at both clinician-individual and clinician-group levels of analysis, you may select “Clinician: Individual and Group (MIPS-Quality only).” Please submit results of individual clinician-level testing in this form and group-level testing results in an attachment. For submission to the MIPS-Cost program, clinician group-level testing is sufficient.	☐ Clinician: Individual only ☐ Clinician: Group ☐ Facility ☐ Clinician: Individual and Group (MIPS-Quality only) ☐ Health plan ☐ Population: Regional and State ☐ Accountable Care Organization ☐ Integrated Delivery System ☐ Medicaid program (e.g., Health Home or 1115) ☐ Population: Community, County or City

Change #13

Location: Page 3, Measure Information, Row 008, ADD YOUR CONTENT HERE column

Reason for Change: Text added for additional setting.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text: Health and drug plans

Change #14

Location: Page 5, Measure Information, Row 009, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Language updated for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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.)? Note: If “Yes”, please describe one score only in this form. Submit separate attachments for each of the other scores.	☐ Yes ☐ No

Change #15

Location: Page 5, new field label row added under row 009

Reason for Change: Added additional field label for additional guidance and clarity of tool use.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 009, then Rows 010-012 become required fields. If you select, “No”, then skip to Row 013.	n/a	This is not a data entry field.

Change #16

Location: Page 5, new row 10 added

Reason for Change: Additional fields required if reporting ‘yes’ to row 009.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	010	*Measures with Multiple Scores: Number of Scores	How many measure scores are recommended for this measure?	Numeric field

Change #17

Location: Page 5, new row 11 added

Reason for Change: Additional fields required if reporting ‘yes’ to row 009.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	011	*Measures with Multiple Scores: Names of Score Reported in MERIT Form	Please enter the name of the score described in this MERIT form.	Free text field

Change #18

Location: Page 5, new row 12 added

Reason for Change: Additional fields required if reporting ‘yes’ to row 009.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	011	*Measures with Multiple Scores: Names of Score Reported in MERIT Form	Please enter the name of the score described in this MERIT form.	Free text field

Change #19

Location: Page 6, new row 13 added

Reason for Change: Field moved to different row in the template.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	013	*Is the measure a composite?	Select one. A composite measure contains two or more individual measures, resulting in a single measure and a single score. If this measure is a composite measure, please enter data relevant to the overall composite into this form. Please attach any additional information pertaining to individual components.	☐ Yes ☐ No

Change #20

Location: Page 6, new row 14 added

Reason for Change: New field

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	014	*Is this a paired measure?	Select one. Paired measures have different measure scores, but results require them to be reported together to be interpreted appropriately. Note: Individual measures comprising a paired measure must be submitted individually.	☐ Yes ☐ No

Change #21

Location: Page 6, new guidance row added under row 14

Reason for Change: Instructions added related to new field.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 014, then Rows 015-016 become required fields. If you select “No” in this field, then skip to Row 017.	n/a	This is not a data entry field.

Change #22

Location: Page 6, new row 15 added

Reason for Change: Field added if ‘yes’ response to row 14.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	015	*How many measures are intended to be paired with this measure?	How many other measures are intended to be paired with this measure? Do not include this measure in the count.	Numeric field

Change #23

Location: Page 6, new row 16 added

Reason for Change: Field added if ‘yes’ response to row 14.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	016	*What are the titles of all measures that should be paired with this measure?	Please enter the measure titles for all other measures that should be paired with this measure. Do not include this measure in the list. Please enter the measure titles separated by a semicolon, and do not enter any additional information in this field.	Free text field

Change #24

Location: Page 7, row 017, column row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 010

CY 2023 Final Rule text: 017

Change #25

Location: Page 7, row 018

Reason for Change: Updated to current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	018	*Numerator Exclusions	For additional information on exclusions/exceptions, see: https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/exclusions. If not applicable, enter 'N/A.'	ADD YOUR CONTENT HERE

Change #26

Location: Page 7, row 019, column row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 012

CY 2023 Final Rule text: 019

Change #27

Location: Page 7, row 020

Reason for Change: Updated to current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	020	*Denominator Exclusions	For additional information on exclusions/exceptions, see: https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/exclusions. If not applicable, enter 'N/A.'	ADD YOUR CONTENT HERE

Change #28

Location: Page 7, row 021

Reason for Change: Updated to current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	021	*Denominator Exceptions	For additional information on exclusions/exceptions, see: https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/exclusions. If not applicable, enter ‘N/A.’	ADD YOUR CONTENT HERE

Change #29

Location: Page 7, row 022

Reason for Change: New field/row added.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Information	022	*Briefly describe the rationale for the measure	Briefly describe the rationale for the measure and/or the impact the measure is anticipated to achieve. Details about the evidence to support the measure will be captured in the Evidence section.	ADD YOUR CONTENT HERE

Change #30

Location: Page 8, row 023

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Implementation	023	*Feasibility of Data Elements	Select one. Select the extent to which the specified data elements are available in electronic fields. Electronic fields should include a designated location and format for the data in claims, EHRs, registries, etc. Select “ALL data elements are in defined fields in electronic sources” if the data elements needed to calculate the measure are all available in discrete and electronically defined fields. Select “Some data elements are in defined fields in electronic sources” if the data elements needed to calculate the measure are not all available in discrete and electronically defined fields. Select “No data elements are in defined fields in electronic sources” if none of the data elements needed to calculate the measure are available in discrete and electronically defined fields. Select “Not applicable" ONLY for measures that are not fully developed OR for CAHPS measures. For a PRO-PM, select the most appropriate option based on the data collection format(s).	☐ 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 ☐ Not applicable

Change #31

Location: Page 8

Reason for Change: Row 016/field removed from template.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #32

Location: Page 9, row 024, Previous row 017 now row 024, Row, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Guidance language and responses updated for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Implementation	024	*Method of measure calculation	Select one. Select the method used to calculate measure scores for the version of the measure proposed in this submission form. Please review guidance before making selections: Select “Electronically Derived Administrative Claims” if the measure can be calculated exclusively from claims data submitted electronically for billing or other purposes. Select “eCQM" if the measure is exclusively specified and formatted to use data from electronic health record (EHRs) and/or health information technology systems, using the Quality Data Model (QDM) to define the data elements and Clinical Quality Language (CQL) to express measure logic. Select “Other digital method” if the measure does not meet the definition of an eCQM as described above, but can be calculated electronically (e.g., registry, MDS, OASIS). Select “Manual abstraction” if all data elements in the measure requires manual review of records, paper-based billing, or manual calculation (e.g., CAHPS). Select “Combination” if two or more types of data sources are required to calculate the measure score. For all other measures that rely on patient surveys (e.g., PRO-PMs), select the option that best describes the way the measure is calculated. For example, if a patient survey is collected electronically and does not require manual abstraction, select "Other digital method" or "eCQM" depending on where the data are collected.	☐ Electronically Derived Administrative Claims ☐ eCQM ☐ Other digital method ☐ Manual abstraction ☐ Combination

Change #33

Location: Page 9, guidance row following row 24

Reason for Change: Language update for change in terms.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Implementation	n/a	If you select "Combination" in Row 024, then Row 025 becomes a required field.	n/a	This is not a data entry field.

Change #34

Location: Page 9, Previous row 018, now row 25.

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Implementation	018	Hybrid measure: Methods of calculation	Select all methods that apply	☐ Claims ☐ eCQM ☐ Other digital method ☐ Manual abstraction

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Implementation	025	*Combination measure: Methods of calculation	Select all that apply. A minimum of two options must be selected.	☐ Electronically Derived Administrative Claims ☐ eCQM ☐ Other digital method ☐ Manual abstraction

Change #35

Location: Page 10, Previous row 019, now row 026

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 019

CY 2023 Final Rule text: 026

Change #36

Location: Page 10, previous row 020

Reason for Change: Row/field removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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

CY 2023 Final Rule text: N/A

Change #37

Location: Page 10, previous row 021, now row 027, row field, guidance field, ADD YOUR CONTENT HERE field

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity and additional option for selection.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Burden	021	*Burden for Provider: Was a provider workflow analysis conducted?	Select one	☐ Yes ☐ No

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Burden	027	*Burden for Provider: Was a provider workflow analysis conducted?	Select one. Select "Not applicable" if the measure imposes no burden on the provider (e.g., CAHPS measures or measures based on administrative data (non-claims), claims data).).	☐ Yes ☐ No ☐ Not applicable

Change #38

Location: Page 10, guidance row following new row 027, Field Label

Reason for Change: Rows references updated for added/removed fields.

CY 2022 Final Rule text: 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.

CY 2023 Final Rule text: If you select “Yes” in Row 027, then Rows 028 and 029 become required fields. If you select “No” in Row 027, then skip to Row 030.

Change #39

Location: Page 10, previous row 022 new row 028, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Burden	028	*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. Select "Not applicable" if the measure does not impose any burden on providers (e.g., CAHPS measures or measures based on administrative data (non-claims) or claims data).	Numeric field

Change #40

Location: Page 11, previous row 023 new row 029, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Burden	023	*Did the provider workflow have to be modified to accommodate the new measure?	Select one	☐ Yes ☐ No

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Burden	029	*Does the provider workflow have to be modified to collect additional data needed to report the measure?	Select one. If workflow modifications required moderate to significant additional data entry from a clinician or other provider to collect the data elements to report the measure because data are not routinely collected during clinical care or EHR interface changes were necessary, select “Yes.” If workflow modifications required no, or limited, additional data entry from a clinician or other provider to collect the data elements to report the measure because data are routinely collected during the clinical care and no EHR interface changes were necessary, select “No.”	☐ Yes ☐ No

Change #41

Location: Page 12, previous row 024 new row 030, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity and updated to current website.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	030	*Reliability	Indicate whether reliability testing was conducted for the accountable entity-level measure scores. Acceptable reliability tests include signal-to-noise (or inter-unit reliability) or random split-half correlation. For more information on accountable entity-level reliability testing, refer to the CMS Measures Management System Blueprint (https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/reliability) Select “Yes” if acceptable accountable entity-level reliability testing has been completed as of submission of this form. Select “No” if you are not able to provide the results of acceptable accountable entity-level reliability testing in this submission. If testing results are incomplete, or if you are submitting a different type of reliability testing, provide as an attachment. Note: This section refers to the reliability of the accountable entity-level measure scores in the final performance measure. For testing of surveys or patient reported tools, refer to the Patient-Reported Data section. Note: for MIPS-Quality 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

Change #42

Location: Page 12, previous guidance row following previous row 024

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text: N/A

Change #43

Location: Page 12, previous row 025 now row 031, Row, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance with addition of command and updated response options.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	031	*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, using data derived from split samples drawn from the same entity at a single point in time.	☐ Signal-to-Noise ☐ Random Split-Half Correlation

Change #44

Location: Page 13, guidance row following row 31, Field Label

Reason for Change: Updated guidance to reflect current fields and tool use.

CY 2022 Final Rule text: 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.

CY 2023 Final Rule text: If you select “Signal-to-Noise” in Row 031, then Rows 032-035 become required fields. If you select, “Random Split-Half Correlation” in Row 032, then Rows 036-039 become required fields.

Change #45

Location: Page 13, previous row 026 now row 032, Row, Field Label, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance and responses for clarity of testing level.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	032	*Signal-to-Noise: Level of Analysis	Select the level of analysis at which the signal-to-noise analysis was conducted. If the measure is specified and intended for use at more than one level, ensure the results in this section are at the same level of analysis selected in the Measure Information section of this form. For MIPS-Quality 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.	☐ Accountable Care Organization ☐ Clinician – Individual only ☐ Clinician – Group only ☐ Facility ☐ Health plan ☐ Integrated Delivery System ☐ Population: Community, County or City ☐ Population: Regional and State

Change #46

Location: Page 13, previous row 027 now row 033, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	033	*Signal-to-Noise: Sample size	Indicate the number of accountable entities sampled to test the final performance measure. Note that this field is intended to capture the number of measured entities and not the number of individual patients or cases included in the sample.	Numeric field

Change #47

Location: Page 13, previous row 028 now row 034, Row, Field Label

Reason for Change: Row numbers adjusted for added/removed fields. Updated language for clarity.

CY 2022 Final Rule text: *Signal-to-Noise: Statistical result

CY 2023 Final Rule text: *Signal-to-Noise: Median Statistical result

Change #48

Location: Page 13, previous row 029 now row 035, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	035	*Signal-to-Noise: Interpretation of results	Describe the type of statistic and interpretation of the results (e.g., low, moderate, high). Provide the distribution of signal-to-noise results across measured entities (e.g., min, max, percentiles). 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

Change #49

Location: Page 14, previous row 030 now row 036, Subsection, Row, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance and response for clarity of testing level.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	036	*Random Split-Half Correlation: Level of Analysis	Select the level of analysis at which the random split-half analysis was conducted. If the measure is specified and intended for use at more than one level, ensure the results in this section are at the same level of analysis selected in the Measure Information section of this form. For MIPS-Quality 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.	☐ Accountable Care Organization ☐ Clinician – Individual only ☐ Clinician – Group only ☐ Facility ☐ Health plan ☐ Integrated Delivery System ☐ Population: Community, County or City ☐ Population: Regional and State

Change #50

Location: Page 14, previous row 031 now row 037, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	037	*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. Note that this field is intended to capture the number of measured entities and not the number of individual patients or cases included in the sample.	Numeric field

Change #51

Location: Page 14, previous row 032 now row 038

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 032

CY 2023 Final Rule text: Row 038

Change #52

Location: Page 14, previous row 033 now row 039, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	039	*Random Split-Half Correlation: Interpretation of results	Describe the type of statistic and 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

Change #53

Location: Page 14, previous row 034 – row removed

Reason for Change: Removed row to streamline testing information required.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text: N/A

Change #54

Location: Page 14, previous row 035 – row removed

Reason for Change: Row removed to streamline testing information required.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text: N/A

Change #55

Location: Page 14, previous row 036 – row removed

Reason for Change: Row removed to streamline testing information required.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #56

Location: Page 14, previous row 037– row removed

Reason for Change: Row removed to streamline testing information required.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #57

Location: Page 15, previous row 038 now row 040, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance to current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	040	*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://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/validity) 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-Quality 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

Change #58

Location: Page 15, n/a row following new row 040, Field Label

Reason for Change: Row references changed due to rows being added/removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 040, then Rows 041-046 become required fields. If you select “No” in Row 040, then skip to Row 047.	n/a	This is not a data entry field.

Change #59

Location: Page 15, previous row 039 now row 041, Row

Reason for Change: Row references changed due to rows being added/removed.

CY 2022 Final Rule text: 039

CY 2023 Final Rule text: 041

Change #60

Location: Page 16, new row 042

Reason for Change: New field for clarity of testing level.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	042	*Empiric Validity: Level of Analysis	Select the level of analysis at which the empiric validity analysis was conducted. If the measure is specified and intended for use at more than one level, ensure the results in this section are at the same level of analysis selected in the Measure Information section of this form. For MIPS-Quality 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.	☐ Accountable Care Organization ☐ Clinician – Individual only ☐ Clinician – Group only ☐ Facility ☐ Health plan ☐ Integrated Delivery System ☐ Population: Community, County or City ☐ Population: Regional and State

Change #61

Location: Page 16, previous row 040 now row 043, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountability Entity Level) Testing	043	*Empiric Validity: Sample size	Indicate the number of accountable entities sampled to test the final performance measure. Note that this field is intended to capture the number of measured entities and not the number of individual patients or cases included in the sample.	ADD YOUR CONTENT HERE

Change #62

Location: Page 16, previous row 041 now row 044

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 041

CY 2023 Final Rule text: 044

Change #63

Location: Page 16, previous row 042 now row 045

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 042

CY 2023 Final Rule text: 045

Change #64

Location: Page 17, previous row 043 now row 046

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 043

CY 2023 Final Rule text: 046

Change #65

Location: Page 17, previous row 044 now row 047, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	047	*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. This item is intended to assess whether face validity testing was conducted on the final performance measure (vs. on the survey). Survey item testing results can be provided in an attachment and described in the Patient-Reported Data Section.	☐ Yes ☐ No

Change #66

Location: Page 17, n/a row following new row 047, Field Label

Reason for Change: Row references changed because rows were removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 047, then Rows 048-051 become required fields. If you select “No” in Row 047, then skip to Row 052.	n/a	This is not a data entry field.

Change #67

Location: Page 17, new row following new row 048

Reason for Change: Updated to clarify testing level.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	048	*Face Validity: Level of Analysis	Select the level of analysis for which experts voted on face validity. If the measure is specified and intended for use at more than one level, ensure the results in this section are at the same level of analysis selected in the Measure Information section of this form. For MIPS-Quality 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.	☐ Accountable Care Organization ☐ Clinician – Individual only ☐ Clinician – Group only ☐ Facility ☐ Health plan ☐ Integrated Delivery System ☐ Population: Community, County or City ☐ Population: Regional and State

Change #68

Location: Page 18, previous row 045 now row 049, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	049	*Face validity: Number of voting experts and patients/caregivers	Indicate the number of experts and patients/caregivers who voted on face validity (specifically, whether the measure could differentiate good from poor quality care among accountable entities).	Numeric field

Change #69

Location: Page 18, previous row 046 now row 050, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 046

CY 2023 Final Rule text: 050

Change #70

Location: Page 18, 051 new row added

Reason for Change: Updated for clarity of testing results.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Score Level (Accountable Entity Level) Testing	051	Face validity: Interpretation	Briefly explain the interpretation of the result, including any disagreement with the face validity of the performance measure.	Free text field

Change #71

Location: Page 19, previous row 047 now row 052, Row, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance and responses for clarity.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	052	*Patient/Encounter Level Testing	Indicate whether patient/encounter level testing of the individual data elements in the final performance measure was conducted (i.e., measure of agreement such as kappa or correlation coefficient). Prior studies of the same data elements may be submitted. Select “Yes” if data element agreement was assessed at the individual data element level or denominator and numerator level as of submission of this form. Select “No” if you are not able to provide the results of data element agreement in this submission. If you are submitting preliminary testing results or a different type of data element testing, provide as an attachment. Select “No” and skip to the Patient-Reported Data section if data element testing was only conducted for a survey or patient reported tool (e.g., internal consistency) rather than data element agreement for the final performance measure. Note: This section includes tests of both data element reliability and validity.	☐ Yes ☐ No ☐ Not applicable

Change #72

Location: Page 19, n/a row following new row 052, Field Label

Reason for Change: Row references changed because rows were added/removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 052, then Rows 053-059 become required fields. If you select “No” in Row 052, then skip to Row 060.	n/a	This is not a data entry field.

Change #73

Location: Page 19, previous row 048 new row 053, Row, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Updated guidance to current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	053	*Type of Analysis	Select all that apply. For more information on patient/encounter level testing, refer to the CMS Measures Management System Blueprint (https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/reliability) 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

Change #74

Location: Page 20, previous row 049 new row 054, Row

Reason for Change: Row references updated because rows were added/removed.

CY 2022 Final Rule text: Row 049

CY 2023 Final Rule text: Row 054

Change #75

Location: Page 20, previous row 050 new row 055, Row, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated responses to include additional statistical options.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	055	*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 ☐ Correlation coefficient ☐ Sensitivity ☐ Positive Predictive Value

Change #76

Location: Page 20, previous row 051 new row 056, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	056	*Statistical Results: Individual Data Element	Indicate the single lowest critical data element result of the statistic selected above. This field is intended to capture the least reliable or valid data element included in the measure. Information about all critical data elements should be provided in the “Interpretation of results” field. If providing Kappa or a correlation coefficient, results should be between -1 and 1. If providing percent agreement, sensitivity, or positive predictive value, results should be between 0% and 100% If not tested at the individual data element level, enter 9999.	Numeric field

Change #77

Location: Page 20, new row 057 added

Reason for Change: Addition of row for clarity of testing information.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	057	*Statistical Results: Overall Denominator	After applying denominator exclusions, indicate the result for the overall denominator of the statistic selected above. If not tested at the denominator level, enter 9999.	Numeric field

Change #78

Location: Page 20, new row 058 added

Reason for Change: Addition of row for clarity of testing information.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	058	*Statistical Results: Overall Numerator	Indicate the result for the overall numerator of the statistic selected above. If not tested at the numerator level, enter 9999.	Numeric field

Change #79

Location: Page 21, previous row 052 new row 059, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient/Encounter Level (Data Element Level) Testing	059	*Interpretation of results	Briefly describe the interpretation of results. Include a list of all data elements tested including their frequency, statistical results, and 95% confidence intervals, as applicable. Include 95% confidence intervals for the overall denominator and numerator results, as applicable. Provide results broken down by test site to demonstrate whether reliability/validity varied between sites, if available. If more room is needed and testing results are included in an attachment (e.g., feasibility scorecard), provide the name of the attachment and location in the attachment. 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.	ADD YOUR CONTENT HERE

Change #80

Location: Page 21, previous row 053 new row 060, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 053

CY 2023 Final Rule text: Row 060

Change #81

Location: Page 21, n/a row following new row 060, Field Label

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 060, then Row 061 becomes a required field. If you select “No” in Row 060, then skip to Row 065.	n/a	This is not a data entry field.

Change #82

Location: Page 22, previous row 054 now row 061, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient-Reported Data	061	*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) 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

Change #83

Location: Page 22, previous row 055 now row 062, Row, Field Label, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated field label, guidance, and response for clarity of testing.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Patient-Reported Data	062	*Survey level testing	Indicate whether each patient survey or patient-reported outcome tool has been validated by a peer reviewed study or empirical testing. For a list of acceptable types of testing, please refer to the latest CMS Blueprint version (https://mmshub.cms.gov/measure-lifecycle/measure-testing/evaluation-criteria/scientific-acceptability/reliability). 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. Select “No” if any of the surveys or tools included in the measure have not been validated.	☐ Yes ☐ No

Change #84

Location: Page 22, previous row 056, row removed

Reason for Change: Row removed to streamline information provided.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #85

Location: Page 22, previous row 057, row removed

Reason for Change: Row removed to streamline information provided.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #86

Location: Page 22, previous row 058, row removed

Reason for Change: Row removed to streamline information provided.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #87

Location: Page 22, previous row 059, row removed

Reason for Change: Row removed to streamline information provided.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #88

Location: Page 22, n/a row following new row 062, Field Label

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 062, then Rows 063-064 become required fields. If you select “No” in Row 062, then skip to Row 065.	n/a	This is not a data entry field.

Change #89

Location: Page 22, previous row 060 now row 063, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 060

CY 2023 Final Rule text: 063

Change #90

Location: Page 23, previous row 061 now row 064, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 061

CY 2023 Final Rule text: 064

Change #91

Location: Page 23, previous row 062 now row 065, Row, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Additional response options provided for clarity.

CY 2022 Final Rule text:

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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	065	*Measure performance - type of score	Select one	☐ Categorical (e.g., yes/no) ☐ Continuous variable (e.g., average) ☐ Count ☐ Frequency Distribution ☐ Non-weighted score/composite scale ☐ Rate ☐ Proportion ☐ Ratio ☐ Weighted score/composite scale ☐ Other (enter here:)

Change #92

Location: Page 23, previous row 063 now row 066, Row, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated response options for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	066	*Measure performance score interpretation	Select one	☐ Better quality = Higher score ☐ Better quality = Lower score ☐ Better quality = Score within a defined interval ☐ Passing score above a specified threshold defines better quality ☐ Passing score below a specified threshold defines better quality

Change #93

Location: Page 24-25, new rows added – n/a row following 066, 067, 068, 069, 070, 071

Reason for Change: Updated with additional instructions for tool use and required fields.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Better quality = Higher score” or “Better quality = Lower score” in Row 066, then Rows 070-079 become required fields. If you select “Better quality = Score within a defined interval” in this field, then Rows 068-079 become required fields. If you select “Passing score above a specified threshold defines better quality” or “Passing score below a specified threshold defines better quality” in this field, then Row 067 and Rows 070-079 become required fields.	n/a	This is not a data entry field
Measure Performance	067	*Passing score	Provide the value that indicates the passing score for the performance measure. Please enter only one value in the response field and do not enter a range of values. If unknown or not available, enter 9999.	Numeric field
Measure Performance	068	*Lower limit of defined interval	Provide the lower limit for the performance score’s defined interval. For example, if the defined interval is 60 - 120 minutes, enter the lower limit of 60 here. Please enter only one value in the response field and do not enter a range of values. If unknown or not available, enter 9999.	Numeric field
Measure Performance	069	*Upper limit of defined interval	Provide the upper limit for the performance score’s defined interval. For example, if the defined interval is 60 – 120 minutes, enter the upper limit of 120 here. Please enter only one value in the response field and do not enter a range of values. If unknown or not available, enter 9999.	Numeric field
Measure Performance	070	*Number of accountable entities included in analysis	Provide the number of accountable entities included in the analysis of the distribution of performance scores described in "Overall mean performance score" -"Overall standard deviation of performance scores." Please enter a single value and do not enter a range. If unknown or not available, enter 9999.	Numeric field
Measure Performance	071	*Number of accountable entities: unit	Provide the unit of accountable entities included in the analysis of the distribution of performance scores described in "Overall mean performance score" -"Overall standard deviation of performance scores."	ADD YOUR CONTENT HERE

Change #94

Location: Page 25, previous row 064 now row 072, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated field label and guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	072	*Overall 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. Please enter only one value in the response field and do not enter a range of values. If this is a proportion measure, provide the mean performance score in percentage form, without the symbol. For example, if the mean performance score is 97.9%, enter 97.9 and not 0.979. If a mean performance score is not available, enter 9999.	Numeric field

Change #95

Location: Page 26, previous row 065 now row 073, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated field and guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	073	*Minimum performance score	Provide the minimum performance score for the testing sample that is relevant to the intended use of the measure. If this is a proportion measure, provide the minimum performance score in percentage form, without the symbol. For example, if the minimum performance score is 85.6%, enter 85.6 and not 0.856. If a minimum performance score is not available, enter 9999.	Numeric field

Change #96

Location: Page 26, new row added 074

Reason for Change: New field to clarify measure performance.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	074	10th percentile	Provide the performance score at the 10th percentile for the testing sample that is relevant to the intended use of the measure. If this is a proportion measure, provide the 10th percentile score in percentage form, without the symbol. For example, if the 10th percentile performance score is 21.2%, enter 21.2 and not 0.212. If a 10th percentile performance score is not available, enter 9999.	Numeric field

Change #97

Location: Page 26, previous row 066 new row 075, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated field label and guidance

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	075	*50th percentile (median)	Provide the median performance score (50th percentile) for the testing sample that is relevant to the intended use of the measure. Please enter only one value in the response field and do not enter a range of values. If this is a proportion measure, provide the median performance score in percentage form, without the symbol. For example, if the median performance score is 85.6%, enter 85.6 and not 0.856. If a median performance score is not available, enter 9999.	Numeric field

Change #98

Location: Page 27, new row added 076

Reason for Change: New field to clarify measure performance.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	076	90th percentile	Provide the performance score at the 90th percentile for the testing sample that is relevant to the intended use of the measure. If this is a proportion measure, provide the 90th percentile score in percentage form, without the symbol. For example, if the 90th percentile performance score is 85.6%, enter 85.6 and not 0.856. If a 90th percentile performance score is not available, enter 9999.	Numeric field

Change #99

Location: Page 27, previous row 067 new row 077, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	077	*Maximum performance score	Provide the maximum performance score for the testing sample that is relevant to the intended use of the measure. If this is a proportion measure, provide the maximum performance score in percentage form, without the symbol. For example, if the maximum performance score is 85.6%, enter 85.6 and not 0.856. If a maximum performance score is not available, enter 9999.	Numeric field

Change #100

Location: Page 27, previous row 068 new row 078, Row, Field Label

Reason for Change: Row numbers adjusted for added/removed fields. Updated field label for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	078	*Overall 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

Change #101

Location: Page 27, new row 079 added

Reason for Change: New field added.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Measure Performance	079	*Is there evidence for statistically significant gaps in measure score performance among select subpopulations of interest defined by one or more social risk factors?	Select one. Social risk factors may include age, race, ethnicity, linguistic and cultural context, sex, gender, sexual orientation, social relationships, residential and community environments, Medicare/Medicaid dual eligibility, insurance status (insured/uninsured), urbanicity/rurality, disability, and health literacy.	☐ Yes ☐ No ☐ Not tested

Change #102

Location: Page 28, previous row 069 new row 080, Subsection, Row, Field Label, Guidance

Reason for Change Row numbers adjusted for added/removed fields. Updated language for clarity.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Importance	080	*Meaningful to Patients. Was input on the final performance measure collected from patients and/or caregivers?	Select one. Input from patients and/or caregivers can include any of the following: Patients Primary caregivers Family Other relatives	☐ Yes ☐ No

Change #103

Location: Page 28, n/a row following new row 080, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 080, then Rows 081 and 082 become required fields. If you select “No” in Row 080, then skip to Row 083.	n/a	This is not a data entry field.

Change #104

Location: Page 28, previous row 070 new row 081, Subsection, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updates to language for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Importance	081	*Denominator: Total number of patients and/or caregivers who responded to the question asking whether information from the measure (e.g., the measured outcome or process) is important to know about AND can help improve care for patients in similar situations or with similar conditions.	Indicate the total number of patients/caregivers who responded.	Numeric field

Change #105

Location: Page 28, previous row 071 new row 082, Subsection, Row, Field Label, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updates to language for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Importance	082	*Numerator: Total number of patients and/or caregivers who agreed that information from the measure (e.g., the measured outcome or process) is important to know about AND can help improve care for patients in similar situations or with similar conditions.	Indicate the total number of patients/caregivers who agreed.	Numeric field

Change #106

Location: Page 28, the following rows were removed – 072, n/a following 072, 073, 074

Reason for Change: Fields removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text: N/A

Change #107

Location: Page 29, previous row 075 new row 083, Subsection, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Updated language for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Importance	083	*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 9999.	Numeric field

Change #108

Location: Pages 29-30, the following rows were added – Row 084, n/a following 084, 085, 086, 087

Reason for Change: Fields added for clarity regarding measure importance and usefulness.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Importance	084	*Were the measured entities (or others) consulted on the final performance measure to assess whether the measure is easy to understand AND is useful for decision-making?	Select one. The assessment of whether the measure is easy to understand AND useful for decision-making may be obtained from measured entities, or others such as consumers, purchasers, policy makers, etc., using any of the following methods: Focus groups Structured interviews Surveys of potential users Notes: This is separate from face validity testing of the performance measure. The desired threshold is 60% or greater of measured entities (or others) who respond in agreement that the information produced by the performance measure is easy to understand AND useful for decision-making.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 084, then Rows 085-086 become required fields. If you select “No” in Row 084, then skip to Row 087.	n/a	This is not a data entry field.
Importance	085	*Denominator: Total number of measured entities (or others) who responded when asked if information produced by the performance measure is easy to understand AND useful for decision-making	Enter the total number of measured entities (or others) who responded when asked if information produced by the performance measure is easy to understand AND useful for decision-making. Notes: This is separate from any face validity testing. The assessment of understandability and decision-making utility of the measure may be obtained from measured entities, or others such as consumers, purchasers, policy makers, etc. The desired threshold is 60% or greater of measured entities (or others) who respond in agreement that the information produced by the performance measure is easy to understand AND useful for decision-making.	Numeric field
Importance	086	*Numerator: Total number of measured entities (or others) who agreed that information produced by the performance measure is easy to understand AND useful for decision-making	Enter the total number of measured entities (or others) who responded in agreement that the information produced by the performance measure is easy to understand AND useful for decision-making. Note: This is separate from face validity testing of the performance measure. The assessment of understandability and decision-making utility of the measure may be obtained from measured entities, or others, such as consumers, purchasers, policy makers, etc., The desired threshold is 60% or greater of those being measured (or others) who respond in agreement that the information produced by the performance measure is easy to understand AND useful for decision-making.	Numeric field
Importance	087	*Estimated impact of the measure: Estimate of annual denominator size: unit	Indicate the unit (e.g., patients) of the estimate of annual denominator size.	Free text field

Change #109

Location: Page 30, the following rows were removed – Row 079, n/a following 076, 077

Reason for Change: Fields removed to streamline tool.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text: N/A

Change #110

Location: Page 31, previous row 078 new row 088, Row, AD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Updated language for clarity.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Background Information	088	*What is the history or background for including this measure on the current year MUC List?	Select one	☐ New measure never reviewed by Measure Applications Partnership (MAP) Workgroup, or used in a CMS program ☐ Submitted previously but not included in 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

Change #111

Location: Page 31, n/a row following new row 088, Field Label

Reason for Change: Rows guidance adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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 088, then skip to Row 101". 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 097-099 become required fields.	n/a	This is not a data entry field.

Change #112

Location: Pages 31 - 33, the following new rows were moved – 089, n/a row following 089, 090, 091, 092, 093, 094, 095, 096. Previous rows 148-156.

Reason for Change: Row numbers adjusted for added/removed fields. Row 90 language updated for clarity. Row 156 language updated for clarity.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Previous Measures	089	*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 089, then Rows 90-97 become required fields. in the Previous Measures section. If you select “No” in Row 089, then skip to Row 98.	n/a	This is not a data entry field.
Previous Measures	090	*In what prior year(s) was this measure published on the Measures Under Consideration List?	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.	☐ 2011 ☐ 2012 ☐ 2013 ☐ 2014 ☐ 2015 ☐ 2016 ☐ 2017 ☐ 2018 ☐ 2019 ☐ 2020 ☐ 2021 ☐ 2022 ☐ Other (enter here):
Previous Measures	091	*What was the MUC ID 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	092	*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	093	*What were the programs that MAP reviewed the measure for in each year?	List both the year and the associated CMS programs in each year.	ADD YOUR CONTENT HERE
Previous Measures	094	*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	095	*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	096	*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	100	*If this measure is being submitted to meet a statutory requirement, list the corresponding statute	List title and other identifying citation information. If this measure is not being submitted to meet a statutory requirement, enter N/A.	ADD YOUR CONTENT HERE

Change #113

Location: Page 33, previous row 079 new row 097, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 079

CY 2023 Final Rule text: Row 097

Change #114

Location: Page 34, previous row 080 new row 098, Row, ADD YOUR CONTENT HERE

Reason for Change Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 080

CY 2023 Final Rule text: Row 098

Change #115

Location: Pages 35 and 36, the following row were added – 099

Reason for Change: Field added for clarity of alignment across programs.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Background Information	099	*How will this measure align with the same measure(s) that are currently used in other federal programs?	Describe how this measure will achieve alignment with the same measure(s) that are currently used in other federal programs. Please include the names of the same measure(s) that are used in other federal programs and include the corresponding unique identifier (e.g., federal program ID, NQF#, etc.), if available. Alignment is achieved when a set of measures works well across care settings or programs to produce meaningful information without creating extra work for those responsible for the measurement. Alignment includes using the same quality measures in multiple programs when possible. It can also come from consistently measuring important topics across care settings.	ADD YOUR CONTENT HERE

Change #116

Location: Page 36, previous row 081 new row 101, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: 081

CY 2023 Final Rule text: 101

Change #117

Location: Page 36, row 102 was added

Reason for Change: Field added for clarity of data sources.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Data Sources	102	*The current measure specifications allow for the utilization of at least one digital data source.	Select “Yes” if measure data sources include at least one of the following: Administrative Claims Administrative Data Patient Assessment Instrument (e.g., MDS, LTCH-CARE, OASIS) EHR Registry (e.g., QCDR and Qualified Registry and EQRS) Select “No” if measure data sources are limited to the following: Chart-Abstracted Survey (For example, currently CAHPS, QRS Survey, HOS are not captured digitally) Part B claims measures (MIPS) reported using Quality Data codes Paper Medical Records	☐ Yes ☐ No

Change #118

Location: Page 36, previous row 082 new row 103, Row

Reason for Change: Rows adjusted for added/removed fields.

CY 2022 Final Rule text: 082

CY 2023 Final Rule text: 103

Change #119

Location: Page 36, previous row 083 new row 104, Row

Reason for Change: Rows adjusted for added/removed fields.

CY 2022 Final Rule text: 083

CY 2023 Final Rule text: 104

Change #120

Location: Page 37, previous row 084 new row 105, Row, Guidance

Reason for Change: Rows adjusted for added/removed fields. Guidance added for clarity.

CY 2022 Final Rule text:

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:

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Steward Information	105	*Measure Steward	Enter the current Measure Steward. Typically, this is an organization or other agency/institution/entity name.	See Appendix A.084-086 for list choices. Copy/paste or enter your choices here:

Change #121

Location: Page 37, previous row 085 new row 106

Reason for Change: Rows adjusted for added/removed fields.

CY 2022 Final Rule text: Row 054

CY 2023 Final Rule text: Row 106

Change #122

Location: Page 37, previous row 086 new row 107, Row, Field Label, ADD YOUR CONTENT HERE

Reason for Change: Rows adjusted for added/removed fields. Field label and responses updated for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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:

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Long-Term Steward Information	107	*Is the long-term steward different than the steward?	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.	☐ Yes ☐ No

Change #123

Location: Page 37, n/a row added after new row 107

Reason for Change: Row added for clarity and streamline tool use.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 107, then Row 108 becomes a required field. If you select “No” in Row 107, then skip to Row 109.	n/a	This is not a data entry field.

Change #124

Location: Page 37, previous row 087 new row 108, Row, Field Label, Guidance

Reason for Change: Rows adjusted for added/removed fields. Updated field label to required and updated guidance for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Long-Term Steward Information	108	*Long-Term Measure Steward Contact Information	If different from Steward above, enter the required contact information for the Long-Term Measure Steward listed above	ADD YOUR CONTENT HERE

Change #125

Location: Page 37, previous row 088 new row 109, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 088

CY 2023 Final Rule text: Row 109

Change #126

Location: Page 37, previous row 089 new row 110, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 089

CY 2023 Final Rule text: Row 110

Change #127

Location: Page 37, previous row 090 new row 111, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 090

CY 2023 Final Rule text: Row 111

Change #128

Location: Page 37, n/a row added after new row 111

Reason for Change: Row added for clarity and streamline tool use.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If applicable, select from drop-down menu “Other MERIT users who will contribute to this measure”	n/a	This is not a data entry field.

Change #129

Location: Page 38, previous row 091 new row 112, Row, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields. Guidance updated to current website and responses updated.

CY 2022 Final Rule text:

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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
General Characteristics	112	*Measure Type	Select only one type of measure. For definitions, see: https://mmshub.cms.gov/about-quality/new-to-measures/types.	☐ Cost/Resource Use ☐ Efficiency ☐ Intermediate Outcome ☐ Outcome ☐ PRO-PM or Patient Experience of Care ☐ Process ☐ Structure

Change #130

Location: Page 38, n/a row following new row 112, Field Label

Reason for Change: Row added for clarity and streamline tool use.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “PRO-PM or Experience of Care” in Row 112, then Row 113 becomes a required field. If you select “Outcome” or “PRO-PM or Experience of Care” in Row 112, then Row 147 in the Evidence section becomes a required field.	n/a	This is not a data entry field.

Change #131

Location: Page 38, new row 113

Reason for Change: Field added to capture experience of care.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
General Characteristics	113	*Assessment of patient experience of care	Select one. Indicate whether this measure assesses patient experience of care.	☐ Yes ☐ No

Change #132

Location: Page 38, previous row 093 new row 114, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 093

CY 2023 Final Rule text: Row 114

Change #133

Location: Page 38, n/a row following new row 114, Field Label

Reason for Change: Row number references adjusted because fields were added/removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 114, then Row 115 becomes a required field. If you select “No” in Row 114, then skip to Row 116.	n/a	This is not a data entry field.

Change #134

Location: Page 38, previous row 094 new row 115, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 094

CY 2023 Final Rule text: Row 115

Change #135

Location: Page 39, previous row 095 new row 116, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Guidance updated for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
General Characteristics	116	Alternate Measure ID	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. DO NOT enter consensus-based entity (endorsement) ID, CMIT ID, or previous year MUC ID in this field.	ADD YOUR CONTENT HERE

Change #136

Location: Page 39, previous row 096 new row 117, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 096

CY 2023 Final Rule text: Row 117

Change #137

Location: Page 39, previous row 097 new row 118, Row, Guidance

Reason for Change: Row numbers adjusted for added/removed fields. Guidance updated for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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:

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
General Characteristics	118	*What one area of specialty the measure is aimed to, or which specialty is most likely to report this measure?	Select the ONE most applicable area of specialty.	See Appendix A.097 for list choices. Copy/paste or enter your choice(s) here:

Change #138

Location: Page 39, previous row 098 new row 119, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 098

CY 2023 Final Rule text: Row 119

Change #139

Location: Page 39, previous row 099 new row 120, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 099

CY 2023 Final Rule text: Row 120

Change #140

Location: Pages 40-47, the following rows were moved 121, n/a row following row 121, 122-132, n/a row following row 132, 133-148; previous rows 100-121; Updates to row 121 and 123, 126, addition of rows 128,129,139,140,141,144,145,146,147 and removal of previous rows 119 and 120.

Reason for Change: Row numbers adjusted for added/removed fields. Update guidance in row 121,123 to current website. Language in row 126 updated in field label, guidance, and responses for clarity. Rows added to provide additional information. Rows removed as information provided in other fields.

CY 2022 Final Rule text:

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 type120	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Evidence	121	*Type of evidence to support the measure	Select all that apply. Refer to the latest CMS Blueprint version (https://mmshub.cms.gov/measure-lifecycle/measure-conceptualization/information-gathering-overview) and the supplementary material related to evidence review (https://mmshub.cms.gov/sites/default/files/Environmental-Scans.pdf) to obtain updated guidance.	☐ Clinical Guidelines or USPSTF (U.S. Preventive Services Task Force) Guidelines ☐ Peer-Reviewed Systematic Review ☐ Peer-Reviewed Original Research ☐ Empirical data ☐ Grey Literature
n/a	n/a	If you select “Clinical Guidelines or USPSTF (U.S. Preventive Services Task Force) Guidelines” in Row 121, then Rows 122-129 become required fields. If you select “Systematic Review” in Row 121, then Rows 131 and 137-139 become required fields. If you select “Empirical data” in Row 121, then Rows 131 and 142-144 become required fields. If you select “Grey Literature” in Row 121, then Rows 131 and 145-147 become required fields.	n/a	This is not a data entry field.
Evidence	122	*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	123	*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://mmshub.cms.gov/measure-lifecycle/measure-conceptualization/information-gathering-overview) and the supplementary material related to evidence review (https://mmshub.cms.gov/sites/default/files/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	124	*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	125	*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	126	*Guideline citation	Provide any of the following: Full citation for the primary clinical guideline in any established citation style (e.g., AMA, APA, Chicago, Vancouver, etc.) URL DOI or ISBN for clinical guideline document	☐ Citation (enter here) ☐ URL (enter here) ☐ DOI (enter here) ☐ Not available
Evidence	127	*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	128	*Does the clinical guideline include a publicly available evidence summary?	Evidence-based clinical guidelines should be accompanied by a publicly available evidence summary. If the guideline includes an evidence summary, please select “Yes” and provide a link to the evidence summary in the text box.	☐ Yes (enter URL here:) ☐ No
Evidence	129	*Is the selected guideline statement used to support an inappropriate use/care measure?	Select one. Indicate whether the guideline statement mentioned in “List the guideline statement that most closely aligns with the measure concept" (row 131) is used to promote the practice of not performing a specific action, process or intervention to support an inappropriate use or inappropriate care measure.	☐ Yes ☐ No
Evidence	130	*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	131	*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	132	*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 132, then Rows 133-138 become required fields.	n/a	This is not a data entry field.
Evidence	133	*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	134	*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	135	*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, Moderate recommendation or similar ☐ USPSTF Grade C or I, Conditional/weak recommendation or similar ☐ Expert Opinion ☐ USPSTF Grade D, Moderate or high certainty that service has no net benefit or harm outweighs benefit ☐ Best Practice Statement/Standard Practice
Evidence	136	*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	137	*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	138	*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 specifications 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. If this is an outcome measure or PRO-PM, indicate how the evidence supports or demonstrates a relationship 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	139	*Peer-reviewed systematic review citation	If more than one article was identified, provide at least one of the following for one key article: Citation URL DOI Provide the complete list of citations with accompanying DOI or URL in a separate attachment.	☐ Citation (enter here:) ☐ URL (enter here:): ☐ DOI (enter here:) ☐ Not available
Evidence	140	*Peer-reviewed original research	If the evidence synthesis provided to support this measure concept was performed using peer-reviewed original research articles, indicate whether a systematic search of the literature was conducted.	☐ Yes (please provide search strategy in an attachment; e.g., years searched, keywords and search terms used, databases used, etc.) ☐ No
Evidence	141	*Peer-reviewed original research citation	If more than one article was identified, provide at least one of the following for one key article: Citation URL DOI Provide the complete list of citations with accompanying DOI or URL in a separate attachment.	☐ Citation (enter here:) ☐ URL (enter here:): ☐ DOI (enter here:) ☐ Not available
Evidence	142	*Source of empirical data	Select all that apply	☐ Peer-reviewed narrative literature review ☐ Published and publicly available reports (e.g., from agencies) ☐ Internal data analysis ☐ Other (enter here)
Evidence	143	*Summarize the empirical data	Provide a summary of the empirical data and how it informs this measure concept. Describe the limitations of the data. 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	144	*Empirical data citation	If more than one empirical data was identified, provide at least one of the following for one key empirical data: Citation URL DOI Provide the complete list of citations with accompanying DOI or URL in a separate attachment.	☐ Citation (enter here:) ☐ URL (enter here:): ☐ DOI (enter here:) ☐ Not available
Evidence	145	*Name grey literature	If more than one grey literature was identified, provide at least one of the following for one key piece of evidence: Citation URL DOI Provide the complete list of citations with accompanying DOI or URL in a separate attachment.	ADD YOUR CONTENT HERE
Evidence	146	*Summarize the grey literature	Provide a summary of the grey literature(s) used to inform this measure concept. Describe the limitations of the data. 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.	ADD YOUR CONTENT HERE
Evidence	147	*Grey literature citation	If more than one grey literature was identified, provide at least one of the following for one key piece of evidence: Citation URL DOI Provide the complete list of citations with accompanying DOI or URL in a separate attachment.	☐ Citation (enter here:) ☐ URL (enter here:): ☐ DOI (enter here:) ☐ Not available
Evidence	148	*Does the evidence discuss a relationship 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 relationship between at least one process, structure, or intervention with the outcome.	☐ Yes ☐ No

Change #141

Location: Page 47, new row added149,

Reason for Change: Row added for additional information.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	149	*Was risk adjustment and/or stratification considered?	Select “Yes” if the measure development process included consideration of risk adjustment and/or stratification, even if the final measure does not include risk adjustment or stratification. While risk adjustment is typically only required for outcome measures, other measure types can select “Yes” if risk adjustment or stratification was considered. Select “No” if neither risk adjustment nor stratification was considered as part of the measure development process.	☐ Yes ☐ No

Change #142

Location: Pages 47-48, new rows added – n/a following 149, 150, n/a following 150, and 151; previous row 122, now row 152

Reason for Change: Added rows for additional information. Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 122; N/A for new row additions

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 149, then Row 150, 152, and 161 become required fields. If you select “No” in Row 149, then skip to Row 163.	n/a	This is not a data entry field.
Risk Adjustment and Stratification	150	*Was a conceptual model outlining the pathway between patient risk factors, quality of care, and the outcome of interest established?	Select “Yes” if a conceptual model was established based on a review of published literature. The conceptual model can be supplemented by other sources of information such as expert opinion or empirical analysis. Select “No” if a conceptual model was not established or the conceptual model was based solely on expert opinion or empirical analysis.	☐ Yes ☐ No
n/a	n/a	If you select “Yes” in Row 150, then Row 151 becomes a required field. If you select “No” in Row 150, then skip to Row 152.	n/a	This is not a data entry field.
Risk Adjustment and Stratification	151	*Were all key risk factors identified in the conceptual model available for testing?	If some key risk factors were not available for testing or inclusion in the risk model/stratification approach, select “No” and describe the anticipated impact on measure scores (e.g., magnitude and direction of bias).	☐ Yes ☐ No (enter here:)
Risk Adjustment and Stratification	152	*Is the measure risk adjusted?	Indicate whether the final measure is risk adjusted.	☐ Yes ☐ No

Change #143

Location: Page 48, n/a row following previous row 122, now following row 152, Field Label

Reason for Change: Row references adjusted because rows were added/removed.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 152, then Rows 153-160 become required fields. If you select “Yes” in Row 152, you are also encouraged to upload documentation about your risk adjustment model as an attachment. If you select “No” in Row 152, then skip to Row 161.	n/a	This is not a data entry field.

Change #144

Location: Page 48, previous row 101 now 122, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 101

CY 2023 Final Rule text: Row 122

Change #145

Location: Page 49, previous row 123 new row 153, Subsection, Row, Field Label, Guidance

Reason for Change: Language updates for clarity and to reflect current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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):

CY 2023 Final Rule text: N/A

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	153	Risk adjustment variable types	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 characteristics” 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 characteristic ☐ Other (enter here):

Change #146

Location: Page 50, n/a row following previous row 123, now row 153, Subsection, Field Label

Reason for Change: Updates to subsection for clarity and field label to reflect row changes.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	n/a	If you select “Patient-Level Demographics” in Row 153, then Row 154 becomes a required field. If you select “Patient-level health status & clinical conditions” in Row 153, then Row 155 becomes a required field. If you select “Patient functional status” in Row 153, then Row 156 becomes a required field. If you select “Patient-level social risk factors” in Row 153, then Row 157 becomes a required field. If you select “Proxy social risk factors” in Row 153, then Row 158 becomes a required field. If you select “Patient community characteristics” in Row 153, then Row 159 becomes a required field.	n/a	This is not a data entry field.

Change #147

Location: Page 50, previous row 124 new row 154, Subsection, Row, Subsection

Reason for Change: Updated subsection for clarity and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment	124	*Patient-level demographics: please select all that apply	Select all that apply	☐ Age ☐ Sex ☐ Gender ☐ Race/ethnicity ☐ Other (enter here):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	154	*Patient-level demographics: please select all that apply	Select all that apply	☐ Age ☐ Sex ☐ Gender ☐ Race/ethnicity ☐ Other (enter here):

Change #148

Location: Page 50, previous row 125 new row 155, Subsection, Row

Reason for Change: Updated subsection for clarity and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	155	*Patient-level health status & clinical conditions: please select all that apply	Select all that apply	☐ Case-Mix Adjustment ☐ Severity of Illness ☐ Comorbidities ☐ Health behaviors/health choices ☐ Other (enter here):

Change #149

Location: Pages 50 and 51, previous rows 126 and 127, now rows 156 and 157, Subsection, Row

Reason for Change: Updated subsection for clarity and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment	125	*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	126	*Patient-level social risk factors: please select all that apply	Select all that apply	☐ Income ☐ Education ☐ Wealth ☐ Living Alone ☐ Social Support ☐ Other (enter here):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	156	*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 and Stratification	157	*Patient-level social risk factors: please select all that apply	Select all that apply	☐ Income ☐ Education ☐ Wealth ☐ Living Alone ☐ Social Support ☐ Other (enter here):

Change #150

Location: Page 51, previous row 128, new row 158, Subsection, Row,

Reason for Change: Updated subsection for clarity and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	158	*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):

Change #151

Location: Page 51, previous row 129, new row 159, Subsection, Row

Reason for Change: Updated subsection for clarity and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT 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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	159	*Patient community characteristics: please select all that apply	Select all that apply	☐ Percent of Vacant Houses ☐ Crime Rate ☐ Urban/Rural ☐ Other (enter here):

Change #152

Location: Page 51, previous row 130 new row 160, Subsection, Row

Reason for Change: Updated subsection for clarity and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment	130	*Risk model performance	Provide empirical evidence that the risk model adequately accounts for confounding factors (e.g., assessment of model calibration and discrimination). Describe your interpretation of the results.	ADD YOUR CONTENT HERE

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	160	*Risk model performance	Provide empirical evidence that the risk model adequately accounts for confounding factors (e.g., assessment of model calibration and discrimination). Describe your interpretation of the results.	ADD YOUR CONTENT HERE

Change #153

Location: Page 51, new row added 161

Reason for Change: Row added for additional clarity.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	161	*Is the measure recommended to be stratified?	Indicate whether the final measure is recommended to be stratified.	☐ Yes ☐ No

Change #154

Location: Page 51, new row n/a following row 161

Reason for Change: Addition of row regarding additional fields/for tool use instructions.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 161, then Row 162 becomes a required field. If you select “No” in Row 161 and “No” in Row 152, then Row 163 becomes a required field.	n/a	This is not a data entry field.

Change #155

Location: Page 51, added new row 162

Reason for Change: Row added for additional information.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	162	*Stratification approach	Describe the recommended stratification approach including the data elements used to stratify scores for at-risk subgroups. Demonstrate that there is sufficient sample size within measured entities to stratify measure scores. If more room is needed, provide testing results as an attachment and list the name of the attachment in this field.	ADD YOUR CONTENT HERE

Change #156

Location: Page 52, previous row 131 new row 163, Subsection, Row, Field Label, Guidance, ADD YOUR CONTENT HERE

Reason for Change: Language updates to reflect stratification in addition to risk adjustment. Updated guidance to current website.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment	131	*Rationale for no 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):

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Risk Adjustment and Stratification	163	*Rationale for using neither risk adjustment nor stratification	Select ALL reasons for not implementing a risk adjustment model or stratification approach in the measure. For more information, refer to the CMS Measures Management System Blueprint Risk Adjustment in Quality Measurement supplement (https://mmshub.cms.gov/sites/default/files/Risk-Adjustment-in-Quality-Measurement.pdf) and the guidance on defining stratification schemes (https://mmshub.cms.gov/measure-lifecycle/measure-specification/develop-specification/stratification)	☐ Addressed through exclusions (e.g., process measures) ☐ Risk adjustment not appropriate based on conceptual or empirical rationale (enter here): ☐ Data were not available to evaluate risk adjustment or stratification (enter here): ☐ Other (enter here):

Change #157

Location: Page 53, previous row 132 new row 164, Row, Field Label, Guidance

Reason for Change: Updated to reflect Meaningful measures 2.0.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Healthcare Domain	164	*What one Meaningful Measures 2.0 priority is most applicable to this measure?	Select the ONE most applicable Meaningful Measures 2.0 priority. 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

CY 2023 Final Rule text: N/A

Change #158

Location: Page 53, added new row 165

Reason for Change: Row added for additional information.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Healthcare Domain	165	What, if any, additional Meaningful Measures 2.0 priorities apply to this measure?	Select up to two additional Meaningful Measures 2.0 priorities that apply to this measure. 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

Change #159

Location: Page 53, added new row 166

Reason for Change: Row added for additional information.

CY 2022 Final Rule text: N/A

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Other Priorities	166	*Does this measure address CMS priorities to improve maternal health care and maternal outcomes?	Select one.	☐ Yes ☐ No

Change #160

Location: Page 53, previous row 133 new row 167, Row, Guidance

Reason for Change: Updated guidance to current website and row numbers adjusted for added/removed fields.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Endorsement Characteristics	167	*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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Endorsement Characteristics	167	*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: https://p4qm.org/	☐ Endorsed ☐ Endorsement removed ☐ Submitted ☐ Failed endorsement ☐ Never submitted

Change #161

Location: Pages 53-54, previous rows 134, 135, n/a following 135, 136 - 139, now 168, 169, n/a following 169, 170-173; updates to n/a row Field Label, rows 172 and 173 ADD CONTENT HERE

Reason for Change: Row numbers adjusted for added/removed fields, n/a field label updated to reflect current rows, and responses updated for rows 172 and 173 for applicable years.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Endorsement Characteristics	168	*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	169	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 169, then Rows 170-171 become required fields.	n/a	This is not a data entry field.
Endorsement Characteristics	170	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	171	If not exactly as endorsed, describe the nature of the differences	Briefly describe the differences	ADD YOUR CONTENT HERE
Endorsement Characteristics	172	If endorsed: Year of most recent CDP endorsement	Select one	☐ 2017 ☐ 2018 ☐ 2019 ☐ 2020 ☐ 2021 ☐ 2022 ☐ 2023
Endorsement Characteristics	173	Year of next anticipated CDP endorsement review	Select one. If you are submitting for initial endorsement, select the anticipated year.	☐ 2022 ☐ 2023 ☐ 2024 ☐ 2025 ☐ 2026 ☐ 2027

CY 2023 Final Rule text: N/A

Change #162

Location: Page 55, previous row 140 new row 174, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 140

CY 2023 Final Rule text: Row 174

Change #163

Location: Page 55, n/a row following new row 174, Field Label

Reason for Change: Row references adjusted because new rows were added.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 174, then Rows 175-177 become required fields. If you select “No” in Row 174, then skip to Row 178.	n/a	This is not a data entry field.

Change #163

Location: Page 55, previous row 141 new row 175, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 141

CY 2023 Final Rule text: Row 175

Change #164

Location: Page 55, previous row 142 new row 176, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 142

CY 2023 Final Rule text: Row 176

Change #165

Location: Page 55, previous row 143 new row 177, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 143

CY 2023 Final Rule text: Row 177

Change #166

Location: Page 55, RELATED AND COMPETING MEASURES section title

Reason for Change: Updated language for clarity.

CY 2022 Final Rule text: SIMILAR MEASURES

CY 2023 Final Rule text: RELATED AND COMPETING MEASURES

Change #167

Location: Page 56, previous row 144 new row 178, Row, Field Label

Reason for Change: Updated language for clarity.

CY 2022 Final Rule text:

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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Similar In-Use Measures	178	*Is this measure similar and/or competing with measure(s) already in a program?	Select either Yes or No. Consider other measures with similar purposes.	☐ Yes ☐ No

Change #168

Location: Page 56, n/a row following new row 178, Field Label

Reason for Change: Row references changed because rows were added.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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.

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
n/a	n/a	If you select “Yes” in Row 178, then Rows 179-181 become required fields. If you select “No” in Row 178, then skip to Row 182.	n/a	This is not a data entry field.

Change #169

Location: Page 56, previous row 145 new row 179, Subsection, Row, Field Label

Reason for Change: Updated language for clarity.

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Related and Competing Measures	179	*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

Change #170

Location: Page 56, previous row 146 new row 180, Subsection, Row, Field Label

Reason for Change: Updated language for clarity

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Related and Competing Measures	180	*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

Change #171

Location: Page 56, previous row 147 new row 181, Subsection, Row, Field Label

Reason for Change: Updated language for clarity

CY 2022 Final Rule text:

Subsection	Row	Field Label	Guidance	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

CY 2023 Final Rule text:

Subsection	Row	Field Label	Guidance	ADD YOUR CONTENT HERE
Related and Competing Measures	181	*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

Change #172

Location: Page 57, previous row 157 new row 182, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 157

CY 2023 Final Rule text: Row 182

Change #173

Location: Page 57, previous row 158 new row 183, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 158

CY 2023 Final Rule text: Row 183

Change #174

Location: Page 57, new SUBMITTER COMMENTS section

Reason for Change: Updated for clarity.

CY 2022 Final Rule text: COMMENTS

CY 2023 Final Rule text: SUBMITTER COMMENTS

Change #175

Location: Page 57, previous row 159 new row 184, Row

Reason for Change: Row numbers adjusted for added/removed fields.

CY 2022 Final Rule text: Row 159

CY 2023 Final Rule text: Row 184

Change #176

Location: Page 59, A.097 Choices for Areas of specialty (097) – removed Occupational therapy, Physical therapy, speech therapy

Reason for Change: Selections no longer available in MERIT.

CY 2022 Final Rule text:

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)

CY 2023 Final Rule text:

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

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

Plastic and reconstructive surgery

Podiatry

Preventive medicine

Primary care

Psychiatry

Public and/or population health

Pulmonary disease

Pulmonology

Radiation oncology

Rheumatology

Sleep medicine

Sports medicine

Surgical oncology

Thoracic surgery

Urology

Vascular surgery
Other (enter in Row 097)