Crosswalk - Appendix E2: Measures under Consideration 2024 Data Template for Candidate Measures

Appendix E2 Measures under Consideration 2024 Data Template for Candidate Measures Crosswalk.pdf

Quality Payment Program (QPP)/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

Crosswalk - Appendix E2: Measures under Consideration 2024 Data Template for Candidate Measures

OMB: 0938-1314

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MUC Data Template Crosswalk
CY 2023 Final Versus CY 2024 Final
Burden Impact: The changes to this form do not reflect policies in the CY 2025 Physician Fee
Scheduled (PFS) Final Rule for the Quality Payment Program. There are no impacts to burden
as a result of any changes reflected here.
Change #1
Location: Title (Page 1)
Reason for Change: Updated date in title of the document.
CY 2023 Final Rule text: Measures Under Consideration Entry/Review and Information Tool
2023 Data Template for Candidate Measures
CY 2024 Final Rule text: Measures Under Consideration Entry/Review and Information Tool
2024 Data Template for Candidate Measures
Change #2
Location: Instructions (Page 1)
Reason for Change: Updated instructions for clarity.
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.
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].
CY 2024 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.”
1

5. For all fields, especially Numerator and Denominator, use plain text whenever possible.
Please convert any special symbols, math expressions, or equations to plain text
(keyboard alphanumeric, such as + - * /).
6. For all free-text fields: Be sure to spell out all abbreviations and define special terms at
their first occurrence.
7. Numeric fields are noted, where applicable, in the “Add Your Content Here” column.
8. Row numbers are for convenience only and do not appear on the CMS MERIT user
interface.
9. Send any questions to [email protected] with the subject line “Pre-Rulemaking”.
Change #3
Location: Whole document, Footer
Reason for Change: Updated the year and date.
CY 2023 Final Rule text: 2023 CMS MERIT DATA TEMPLATE; 1/30/2023
CY 2024 Final Rule text: 2024 CMS MERIT DATA TEMPLATE; 1/31/2024
Change #4
Location: Whole document, ADD YOUR CONTENT HERE column
Reason for Change: To provide additional clarity to submitters.
CY 2023 Final Rule text: ADD YOUR CONTENT HERE
CY 2024 Final Rule text: Free text field
Change #5
Location: Page 2, Measure Information, Row 002, Field Label column
Reason for Change: Capitalized the title.
CY 2023 Final Rule text: Measure description
CY 2024 Final Rule text: Measure Description

Change #6
Location: Page 3, Measure Information, Row 003
Reason for Change: Updated Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

003

*Select the CMS

Select all that apply. Please note,
measures specified and intended for
use at more than one level of analysis
must be submitted separately for each
level of analysis (e.g., individual
clinician, facility). If you choose multiple
programs for this submission, please
ensure the programs fall under the
same level of analysis. If you choose
multiple programs and need guidance
as to whether your selection represents
multiple levels of analysis, please
contact [email protected].
There is functionality within CMS MERIT
to decrease the data entry process for
multiple submissions of the same
measure. Please reach out to
[email protected]
for guidance and support.

☐ 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
This is not a data entry field.

program(s) for
which the measure
is being submitted.

If you are submitting for MIPS, there
are two choices of program. Do NOT
enter both MIPS-Quality and MIPS-Cost
for the same measure. Choose MIPSQuality for measures that pertain to
quality and/or efficiency. Choose MIPSCost only for measures that pertain to
cost.

n/a

If you select “Meritbased Incentive
Payment System Quality” in Row
003, then Row 004
becomes an
optional field.

n/a

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

003

*Select the CMS

☐ 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
☐ Medicare Shared Savings Program
☐ Merit-based Incentive Payment System-Cost
☐ Merit-based Incentive Payment System-Quality
☐ Part C Star Ratings
☐ Part D Star Ratings
☐ 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
This is not a data entry field.

program(s) for
which the measure
is being submitted.

If you choose multiple programs for this
submission, please ensure the
programs fall under the same level of
analysis. If you choose multiple
programs and need guidance as to
whether your selection represents
multiple levels of analysis, please
contact [email protected].
There is functionality within CMS MERIT
to decrease the data entry process for
multiple submissions of the same
measure. Please reach out to
[email protected]
for guidance and support.
If you are submitting for MIPS, there
are two choices of program. Do NOT
enter both MIPS-Quality and MIPS-Cost
for the same measure. Choose MIPSQuality for measures that pertain to
quality and/or efficiency. Choose MIPSCost only for measures that pertain to
cost.
n/a

n/a

If you select “Meritbased Incentive
Payment System Quality” in Row 003,
then Row 004
becomes an
optional field. If you
do not select
“Merit-based
Incentive Payment
System -Quality” in
Row 003, then skip
to Row 005.

n/a

Change #7
Location: Page 4, Measure Information, Row 005
Reason for Change: Updated Field Label, Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

005

*Stage of
Development

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.

☐ Conceptualization
☐ Specification
☐ Field (Beta) Testing
☐ Fully Developed

For additional information regarding
stage of development, see:
https://mmshub.cms.gov/blueprintmeasure-lifecycle-overview.
n/a

n/a

If you select
“Conceptualization,”
“Specification”, or
“Field (Beta)
Testing” in Row 005,
then Row 006
becomes a required
field. If you select
“Fully Developed” in
Row 005, then skip
to Row 007.

n/a

This is not a data entry field.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

005

*Completed
Stage(s) of
Development

Select all stages of development that
have been completed. There are five
stages in the Measure Lifecycle:
conceptualization; specification;
testing; implementation; and use,
continuing evaluation, and
maintenance. Measure
conceptualization is the first stage;
however, the stages are not necessarily
sequential. Instead, the stages are
iterative and can occur concurrently.

☐ Measure Conceptualization
☐ Measure Specification
☐ Measure Testing
☐ Measure Use, Continuing Evaluation & Maintenance

The measure conceptualization stage
initiates information gathering and
business case development.
The measure specification stage
involves establishing the basic elements
of the measure, including the
numerator, calculation algorithm, and
data source identification.
The measure testing stage examines
the specifications, usually with a limited
number of real settings, to make sure

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

the measure is scientifically acceptable
and feasible.
Measure specification and measure
testing are iterative.

n/a

If you select only
“Measure
Conceptualization”
and/or “Measure
Specification” in
Row 005, then Row
006 becomes a
required field. If
your selections
include “Measure
Testing” or
“Measure Use,
Continuing
Evaluation &
Maintenance” in
Row 005, then skip
to Row 007.

For additional information regarding
stage of development, see:
https://mmshub.cms.gov/blueprintmeasure-lifecycle-overview.
n/a

This is not a data entry field.

Change #8
Location: Page 5, Measure Information, Row 006
Reason for Change: Updated Guidance.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

006

* Stage of
Development
Details

If “Conceptualization,” “Specification,”
or “Field (Beta) Testing,” describe when
testing is planned (i.e., specific dates),
what type of testing is planned (e.g.,
alpha, beta) as well as the types of
facilities in which the measure will be
tested.

ADD YOUR CONTENT HERE

For additional information, see:
https://mmshub.cms.gov/blueprintmeasure-lifecycle-overview.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

006

*Stage of

If testing is not yet completed, describe
when testing is planned (i.e., specific
dates), what type of testing is planned
(e.g., alpha, beta) as well as the types of
facilities in which the measure will be
tested.

Free text field

Development
Details

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

For additional information, see:
https://mmshub.cms.gov/blueprintmeasure-lifecycle-overview.

Change #9
Location: Page 5, Measure Information, Row 007
Reason for Change: Updated Guidance and selection options.
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.

☐ Clinician: Individual only
☐ Clinician: Group/Practice only
☐ Facility
☐ Clinician: Individual and Group (MIPS-Quality only)
☐ Health plan
☐ Population: Regional and State
☐ Accountable Care Organization

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 (MIPSQuality 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.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

007

*Level of Analysis

☐ Accountable Care Organization
☐ Clinician: Group
☐ Clinician: Individual
☐ Clinician: Individual and Group
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City
☐ Population: Regional and State

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

“Clinician: Individual and Group.”
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.

Change #10
Location: Page 6, Measure Information, Row 008
Reason for Change: Updated selection options.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

008

*In which setting(s)

Select all that apply.

☐ Ambulatory surgery center
☐ Ambulatory/office-based care
☐ Behavioral health clinic
☐ Inpatient psychiatric facility
☐ Community hospital
☐ Dialysis facility
☐ Emergency department
☐ Federally qualified health center (FQHC)
☐ Health and drug plans
☐ Hospital outpatient department (HOD)
☐ Home health
☐ Hospice
☐ Hospital inpatient acute care facility
☐ Inpatient rehabilitation facility
☐ Long-term care hospital
☐ Nursing home
☐ PPS-exempt cancer hospital
☐ Skilled nursing facility
☐ Veterans Health Administration facility
☐ Not yet tested
☐ Other (enter here):

was this measure
tested?

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

008

*In which setting(s)

Select all that apply.

☐ Ambulatory surgery center
☐ Ambulatory/office-based care
☐ Behavioral health clinic
☐ Community hospital
☐ Dialysis facility
☐ Emergency department
☐ Federally qualified health center (FQHC)
☐ Health and Drug Plans
☐ Hospital outpatient department (HOD)
☐ Home health
☐ Hospice

was this measure
tested?

☐ Hospital inpatient acute care facility
☐ Inpatient psychiatric facility
☐ Inpatient rehabilitation facility
☐ Long-term care hospital
☐ Nursing home
☐ PPS-exempt cancer hospital
☐ Skilled nursing facility
☐ Veterans Health Administration facility
☐ Not yet tested
☐ Other (enter here):

Change #11
Location: Page 6, Measure Information, Row 009, Guidance
Reason for Change: Updated Guidance and skip logic.
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.
Note: If “Yes”, indicate which score will
be described in this form. Submit
separate attachments for each of the
other scores.

☐ Yes
☐ No

If you select “Yes” in
Row 009, then Row
010-012 becomes a
required field. If you
select, “No”, then
skip to row 013.

CY 2024 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
separately reported for this measure
(e.g., 7- and 30-day rate, rates for
different procedure types, etc.)? This
does not include index measures,
where component measure scores
result in one overall index score. Note:
If “Yes”, please describe one score only
in this form. Submit separate
attachments for each of the other
scores.

☐ Yes
☐ No

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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 #12
Location: Page 7, Row 013 and 014
Reason for Change: Combined composite and paired questions and updated skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

013

*Is the measure a

☐ Yes
☐ No

Measure
Information

014

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.
Select one. Paired measures have
different measure scores, but results
require them to be reported together
to be interpreted appropriately.

composite?

*Is this a paired

measure?

☐ Yes
☐ No

Note: Individual measures comprising a
paired measure must be submitted
individually.
n/a

n/a

If you select “Yes” in
Row 014, then Row
015-016 become
required fields. If
you select “No” in
this field, then skip
to row 017.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

013

*Is the measure a

Select all that apply.

☐ Yes, this is a composite measure
☐ Yes, this is a paired measure
☐ No, this is neither a composite nor a paired measure

composite and/or a
paired measure?

A composite measure contains two or
more individual measures, resulting in a
single measure and a single score. This
includes index measures. If this
measure is a composite measure,
please enter data pertaining to the
overall composite measure into this
form. Please attach any additional
information pertaining to individual
components.

Subsection

n/a

Row

n/a

Field Label

If you select “Yes,
this is a paired
measure” in Row
013, then Rows 014015 become
required fields. If
you do not select
“Yes, this is a paired
measure” in this
field, then skip to
Row 016.

Guidance

ADD YOUR CONTENT HERE

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.
n/a

This is not a data entry field.

Change #13
Location: Page 7, Row 014
Reason for Change: Re-ordered row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

015

*How many

How many other measures are
intended to be paired with this
measure? Do not include this measure
in the count.

Numeric field

measures are
intended to be
paired with this
measure?

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

014

*How many

How many other measures are
intended to be paired with this
measure? Do not include this measure
in the count.

Numeric field

measures are
intended to be
paired with this
measure?

Change #14
Location: Page 7, Row 015
Reason for Change: Re-ordered row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

016

*What are the titles

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

Free text field

of all measures that
should be paired
with this measure?

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

measure titles separated by a
semicolon, and do not enter any
additional information in this field.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

015

*What are the titles

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

of all measures that
should be paired
with this measure?

Change #15
Location: Page 8, Row 016
Reason for Change: Re-ordered row number and updated Guidance.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

017

*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.

ADD YOUR CONTENT HERE

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.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

016

*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.

Free text field

Change #16
Location: Page 8, Row 017
Reason for Change: Re-ordered row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

018

*Numerator

For additional information on
exclusions/exceptions, see:
https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluationcriteria/scientificacceptability/exclusions. If not
applicable, enter 'N/A.'

ADD YOUR CONTENT HERE

Exclusions

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

017

*Numerator

Free text field

Exclusions

Change #17
Location: Page 8, Row 018
Reason for Change: Re-ordered row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

019

*Denominator

The lower part of a fraction used to
calculate a rate, proportion, or ratio.
The denominator is associated with a
given population that may be counted
as eligible to meet a measure’s
inclusion requirements.

ADD YOUR CONTENT HERE

Guidance
The lower part of a fraction used to
calculate a rate, proportion, or ratio.
The denominator is associated with a
given population that may be counted
as eligible to meet a measure’s
inclusion requirements.

ADD YOUR CONTENT HERE
Free text field

CY 2024 Final Rule text:
Subsection
Measure
Information

Row
018

Field Label

*Denominator

Change #18
Location: Page 8, Row 019
Reason for Change: Re-ordered row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

020

*Denominator

ADD YOUR CONTENT HERE

Exclusions

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

019

*Denominator

Free text field

Exclusions

Change #19
Location: Page 8, Row 020
Reason for Change: Re-ordered row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

021

*Denominator
Exceptions

ADD YOUR CONTENT HERE

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

020

*Denominator

Free text field

Exceptions

Change #20
Location: Page 8, Row 021
Reason for Change: Re-ordered row number.
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

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Information

021

*Briefly describe

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.

Free text field

the rationale for the
measure

Change #21
Location: Page 9, Measure Implementation, Row 022
Reason for Change: Re-ordered row number. Updated Guidance, selection options, and skip
logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Implementation

023

*Feasibility of Data

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.

Elements

• 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

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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).

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Implementation

022

*Feasibility of Data
Elements

☐ 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 (applies only for CAHPS measures)
☐ Unable to determine (applies only if a feasibility
assessment has not yet been completed)

n/a

If you select “ALL
data elements are
in defined fields in
electronic sources”
or “Some data
elements are in
defined fields in
electronic sources
in Row 022, then
Row 023 becomes a
required field,
otherwise, skip to
row 024.

For a PRO-PM, select the most
appropriate option based on the data
collection format(s).
n/a

This is not a data entry field.

Change #22
Location: Page 10, Measure Implementation, Row 023
Reason for Change: Added row for USCDI Data Elements.
CY 2023 Final Rule text: N/A
CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Implementat
ion

023

*USCDI Data

Select one. Indicate the extent to which
the data elements that are in defined
fields in electronic sources align with
United States Core Data for
Interoperability (USCDI) v4 or USCDI+
Quality draft standard definitions.

☐ ALL data elements align with USCDI/USCDI+ Quality
standard definitions
☐ Some data elements align with USCDI/USCDI+
Quality standard definitions
☐ None of the data elements align with USCDI/USCDI+
Quality standard definitions
☐ USCDI/USCDI+ Quality alignment not assessed

Elements

For more information about USCDI,
please refer to the HealthIT.gov website
available at:
https://www.healthit.gov/isa/unitedstates-core-data-interoperability-uscdi
For more information about USCDI+
Quality, please refer to the HealthIT.gov
website available at:
https://www.healthit.gov/topic/interop
erability/uscdi-plus

Change #23
Location: Page 11, Measure Implementation, Row 024
Reason for Change: Updated Field Label, Guidance, selection options, and skip logic.
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

☐ Electronically Derived Administrative Claims
☐ eCQM
☐ Other digital method
☐ Manual abstraction
☐ Combination

Subsection

Measure
Implementation

Row

n/a

Field Label

If "Combination" is
selected in this
field, then
"Combination
measure: Methods
of calculation"
becomes a required
field.

Guidance

ADD YOUR CONTENT HERE

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.
n/a

This is not a data entry field.

CY 2024 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 Data (Claims and/or
Non-Claims)” if the measure can be
calculated exclusively from
administrative 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 Derived Administrative Data (Claims
and/or Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction
☐ Combination

Subsection

Measure
Implementation

Row

n/a

Field Label

If you select
"Combination" in
Row 024, then Row
025 becomes a
required field;
otherwise, skip to
Row 026.

Guidance

ADD YOUR CONTENT HERE

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.
n/a

This is not a data entry field.

Change #24
Location: Page 11, Measure Implementation, Row 025
Reason for Change: Updated selection options.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Implementation

025

*Combination

Select all that apply. A minimum of
two options must be selected.

☐ Electronically Derived Administrative Claims
☐ eCQM
☐ Other digital method
☐ Manual abstraction

measure: Methods
of calculation

CY 2024 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 Data (Claims
and/or Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction

Change #25
Location: Page 12, Measure Implementation, Row 026
Reason for Change: Corrected typographical error in Guidance and updated selection options.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Implementation

026

*How is the

This is the anticipated data submission
method. Select all that apply. Use the”
Submitter Comments” field to specify
or elaborate on the type of reporting
data, if needed to define your
measure.

☐ eCQM
☐ Clinical Quality Measure (CQM) Registry
☐ Claims
☐ Web interface
☐ Other (enter here):

measure expected
to be reported to
the program?

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Implementation

026

*How is the

This is the anticipated data submission
method. Select all that apply. Use the
“Submitter Comments” field to specify
or elaborate on the type of reporting
data, if needed to define your
measure.

☐ eCQM
☐ Clinical Quality Measure (CQM)
☐ Claims
☐ Web interface
☐ Other (enter here):

measure expected
to be reported to
the program?

Change #26
Location: Page 13, Burden
Reason for Change: Removed Burden for provider and evaluation site rows.
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., measures based on
administrative data (non-claims), claims
data, or a combination of both, OR if
this is a Consumer Assessment of
Healthcare Providers and Systems
(CAHPS) measure).

☐ Yes
☐ No
☐ Not applicable

n/a

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.

n/a

This is not a data entry field.

Subsection
Burden

Row
028

Field Label

*If yes, how many

sites were
evaluated in the
provider workflow
analysis?

Guidance
Enter the number of sites that were
evaluated in the provider workflow
analysis.

ADD YOUR CONTENT HERE
Numeric field
☐ Not applicable

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).

CY 2024 Final Rule text: N/A
Change #27
Location: Page 13, Burden, Row 027
Reason for Change: Updated row number, Guidance, and selection options.
CY 2023 Final Rule text:
Subsection
Burden

Row
029

Field Label

*Does the provider
workflow have to
be modified to
collect additional
data needed to
report the
measure?

Guidance
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.”

ADD YOUR CONTENT HERE
☐ Yes
☐ No

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.”

CY 2024 Final Rule text:
Subsection
Burden

Row
027

Field Label

*Did the provider
workflow have to
be modified to
collect additional
data needed to
report the
measure?

Guidance
Select one.
Select “Yes” if workflow modifications
impose moderate to significant
additional data entry burden on 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.

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable
☐ Unable to determine

Select “No” if workflow modifications
impose no or limited additional data
entry burden on a clinician or other
provider to collect the data elements to
report the measure because data are

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

routinely collected during the clinical
care, AND no EHR interface changes
were necessary.
Select "Not applicable" if the measure
imposes no data entry burden on the
clinician or provider because:
A) the measure is calculated by
someone other than the clinician or
provider AND uses data that are
routinely generated (i.e.,
administrative data and claims), OR
B) the data are collected by
someone other than the clinician or
provider (e.g., CAHPS), OR
C) the measure repurposes existing
data sets to calculate a measure
score (e.g., HEDIS).
Select "Unable to determine” if a
workflow analysis was not completed
and/or it cannot be determined
whether the workflow modifications
impose additional data entry burden to
collect data needed to report the
measure.

Change #28
Location: Page 14, Groups, Rows 028-031
Reason for Change: Relocated Groups section. Added and removed questions. Updated
Guidance and skip logic.
CY 2023 Final Rule text:

GROUPS

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

n/a

174

*Is this measure an
electronic clinical
quality measure
(eCQM)?

☐ Yes
☐ No

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.

Select 'Yes' or 'No'. If your answer is
yes, the Measure Authoring Tool (MAT)
ID number must be provided below. For
more information on eCQMs, see:
https://www.emeasuretool.cms.gov/
n/a

This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

n/a

175

* Measure

You must attach Bonnie test cases for
this measure, with 100% logic coverage
(test cases should be appended),
attestation that value sets are
published in Value Set Authority Center
(VSAC), and feasibility scorecard. If not
an eCQM, or if MAT number is not
available, enter 0.
Select 'Yes' or 'No'. For additional
information on HQMF standards, see:
https://ecqi.healthit.gov/tool/hqmf

ADD YOUR CONTENT HERE

Select “Yes” if any of the EHR systems
tested had to modify how data were
entered by providers or stored to
facilitate calculation of the eCQM.

☐ Yes
☐ No

Authoring Tool
(MAT) Number

n/a

176

n/a

177

* If eCQM, does the
measure have a
Health Quality
Measures Format
(HQMF)
specification in
alignment with the
latest HQMF and
eCQM standards,
and does the
measure align with
Clinical Quality
Language (CQL) and
Quality Data Model
(QDM)?

* If eCQM, does

any electronic
health record (EHR)
system tested need
to be modified?

☐ Yes
☐ No

Select “No” if the data needed to
calculate the eCQM were already
included in structured fields in the EHR
systems tested and none of them
needed to be modified.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Groups

028

*Is this measure an

Select 'Yes' or 'No'. If your answer is
yes, the Measure Authoring Tool (MAT)
ID number must be provided below. For
more information on eCQMs, see:
https://www.emeasuretool.cms.gov/

☐ Yes
☐ No

If you select “Yes” in
Row 028, then Rows
029-031 become
required fields. If
you select “No” in
Row 028, then skip
to Row 032.

n/a

This is not a data entry field.

ADD YOUR CONTENT HERE

electronic clinical
quality measure
(eCQM)?
Groups

n/a

Groups

029

*Measure

Authoring Tool
(MAT) Number

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Groups

030

Select 'Yes' or 'No'. For additional
information on HQMF standards, see:
https://ecqi.healthit.gov/tool/hqmf

☐ Yes
☐ No

Groups

031

*If eCQM, does the
measure have a
Health Quality
Measures Format
(HQMF)
specification in
alignment with the
latest HQMF and
eCQM standards,
and does the
measure align with
Clinical Quality
Language (CQL) and
Quality Data Model
(QDM)?

Enter the number of unique EHR
vendors represented in the dataset to
demonstrate that measure data
elements are valid and that the
measure score can be accurately
calculated across different systems
(e.g., Epic, Cerner, etc.).

Numeric field

*Number of unique

EHR vendors
represented in
testing dataset

Change #29
Location: Page 15-19, Measure Score Level (Accountable Entity Level) Testing, Row 032-045
Reason for Change: Relocated Measure Score Level (Accountable Entity Level) Testing rows.
Removed and added new rows. Updated Guidance.
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 entitylevel 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/measurelifecycle/measure-testing/evaluationcriteria/scientificacceptability/reliability) Select “Yes” if
acceptable accountable entity-level
reliability testing has been completed
as of submission of this form.

☐ Yes
☐ No

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.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Note: This section refers to the
reliability of the accountable entitylevel 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.
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_r
eports/TR653.html).

☐ Signal-to-Noise
☐ Random Split-Half Correlation

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.
n/a

n/a

Measure
Score Level
(Accountable
Entity Level)
Testing

032

If you select “Signalto-Noise,” in Row
031, then Rows 032035 become
required fields. If
you select, “Random
Split-Half
Correlation,” in Row
032, then Rows 036039 become
required fields.

*Signal-to-Noise:
Level of Analysis

n/a

This is not a data entry field.

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 clinicianlevel testing. If group-level testing is
available, you may submit those results
as an attachment.
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

Numeric field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

number of individual patients or cases
included in the sample.
Measure
Score Level
(Accountable
Entity Level)
Testing

034

Measure
Score Level
(Accountable
Entity Level)
Testing

035

Measure
Score Level
(Accountable
Entity Level)
Testing

036

Indicate the median result for the
signal-to-noise analysis used to assess
accountable entity level reliability.
Results should range from 0.00 to 1.00.
Calculate reliability as the measure is
intended to be implemented (e.g., after
applying minimum denominator
requirements, appropriate type of
setting, provider, etc.).

Numeric field

*Signal-to-Noise:

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

*Random Split-Half

☐ Accountable Care Organization
☐ Clinician – Individual only
☐ Clinician – Group only
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Population: Community, County or City
☐ Population: Regional and State
☐ Count
☐ Frequency Distribution
☐ Non-weighted score/composite/scale
☐ Rate
☐ Weighted score/composite/scale

*Signal-to-Noise:

Median Statistical
result

Interpretation of
results

Correlation: Level of
Analysis

For MIPS-Quality submissions, you must
report the results of individual clinicianlevel testing. If group-level testing is
available, you may submit those results
as an attachment.

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

037

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

038

*Random Split-Half

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

*Random Split-Half

Indicate the statistical result for the
random split-half correlation analysis
used to assess accountable entity level
reliability. Results should range from 1.00 to 1.00. Calculate reliability as the
measure is intended to be implemented
(e.g., after applying minimum
denominator requirements,

Numeric field

Correlation: Sample
size

Correlation:
Statistical result

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

appropriate type of setting, provider,
etc.).
Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

039

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

040

*Random Split-Half

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

*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/measurelifecycle/measure-testing/evaluationcriteria/scientific-acceptability/validity)

☐ Yes
☐ No

Correlation:
Interpretation of
results

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.
n/a

n/a

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

041

Measure
Score Level

042

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.

*Empiric Validity:

Statistic name

n/a

This is not a data entry field.

Indicate the name for the statistic used
to assess accountable entity level
validity. Describe whether the result is a
relative risk, odds ratio, relative
difference in scores, etc.

ADD YOUR CONTENT HERE

If more than one test or comparison
was conducted, describe the statistic
that most strongly supported the
validity of the measure and provide the
full testing results under the “Methods
and findings” question or as an
attachment.

*Empiric Validity:
Level of Analysis

Select the level of analysis at which the
empiric validity analysis was conducted.

☐ Accountable Care Organization
☐ Clinician – Individual only

Subsection

Row

Field Label

(Accountable
Entity Level)
Testing

Guidance

ADD YOUR CONTENT HERE

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.

☐ Clinician – Group only
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Population: Community, County or City
☐ Population: Regional and State

043

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

044

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

045

* Empiric Validity:

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

*Empiric Validity:
Statistical result

Indicate the statistical result. Calculate
empiric validity as the measure is
intended to be implemented (e.g., after
applying minimum denominator
requirements, etc.).

Numeric field

Sample size

If more than one test or comparison
was conducted, provide the result that
most strongly supports the validity of
the measure and provide the full testing
results under the “Methods and
findings” question or as an attachment.

*Empiric Validity:

Methods and
findings

Describe the methods used to assess
accountable entity level validity.
Describe the comparison groups or
constructs used to verify the validity of
the measure scores, including
hypothesized relationships (e.g.,
expected to be positively or negatively
correlated). Describe your findings for
each analysis conducted, including the
statistical result provided above and the
strongest and weakest results across
analyses. If applicable, include the
precision of the statistical result(s) (e.g.,
95% confidence interval) and/or an
assessment of statistical significance
(e.g., p-value). If methods and results
require more space, include as an
attachment.

ADD YOUR CONTENT HERE

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

032

*Reliability

Indicate whether reliability testing was
conducted for the accountable entitylevel 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 Blueprint
content on the CMS Measures
Management System (MMS) Hub
(https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluationcriteria/scientificacceptability/reliability).

☐ Yes
☐ No

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 entitylevel 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.
n/a

n/a

Measure
Score Level
(Accountable
Entity Level)
Testing

033

If you select “Yes” in
Row 032, then Row
33 becomes a
required field. If you
select “No” in Row
032, then skip to
Row 042.

*Reliability: Type of
analysis

n/a

This is not a data entry field.

Select all that apply.

☐ Signal-to-Noise
☐ Random Split-Half Correlation

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_r
eports/TR653.html).

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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.
n/a

n/a

Measure
Score Level
(Accountable
Entity Level)
Testing

034

If you select “Signalto-Noise” in Row
033, then Rows 034037 become
required fields. If
you select, “Random
Split-Half
Correlation” in Row
033, then Rows 038041 become
required fields.

*Signal-to-Noise:
Level of Analysis

n/a

This is not a data entry field.

☐ Accountable Care Organization
☐ Clinician – Group
☐ Clinician – Individual
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City
☐ Population: Regional and State

035

Measure
Score Level
(Accountable
Entity Level)
Testing

036

Measure
Score Level
(Accountable
Entity Level)
Testing

037

*Signal-to-Noise:

Numeric field

*Signal-to-Noise:

Numeric field

*Signal-to-Noise:

Free text field

Sample size

Median Statistical
result

Interpretation of
results

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

assessment of statistical significance
(e.g., p-value).
Measure
Score Level
(Accountable
Entity Level)
Testing

038

*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 clinicianlevel testing. If group-level testing is
available, you may submit those results
as an attachment.

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

039

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

040

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

041

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

042

*Random Split-Half

Numeric field

*Random Split-Half

Numeric field

*Random Split-Half

Free text field

*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 Blueprint content
on the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluationcriteria/scientific-acceptability/validity)

☐ Yes
☐ No

Correlation: Sample
size

Correlation:
Statistical result

Correlation:
Interpretation of
results

Note: This section refers to the empiric
validity of the accountable entity level

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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.
n/a

n/a

Measure
Score Level
(Accountable
Entity Level)
Testing

043

If you select “Yes” in
Row 042, then Rows
043-046 become
required fields. If
you select “No” in
Row 042, then skip
to Row 047.

*Empiric Validity:
Level of Analysis

n/a

This is not a data entry field.

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.

044

Measure
Score Level
(Accountabili
ty Entity
Level)
Testing

045

*Empiric Validity:

Numeric field

*Empiric Validity:

Describe the methods used to assess
accountable entity level validity.
Describe the comparison groups or
constructs used to verify the validity of
the measure scores, including
hypothesized relationships (e.g.,
expected to be positively or negatively
correlated). Describe your findings for
each analysis conducted, including the
statistical results and the strongest and
weakest results across analyses. If
applicable, include the precision of the
statistical result(s) (e.g., 95%
confidence interval) and/or an
assessment of statistical significance
(e.g., p-value). If methods and results
require more space, include as an
attachment.

Free text field

Sample size

Methods and
findings

Change #30
Location: Page 19, Measure Score Level (Accountable Entity Level Testing), Row 047
Reason for Change: Updated Guidance and skip logic.
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.

☐ Yes
☐ No

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.

CY 2024 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.

☐ Yes
☐ No

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 and is
not intended to assess whether patientreported surveys or tools have face
validity. Survey item testing results can
be provided in an attachment and
described in the Patient-Reported Data
Section.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

n/a

If you select “Yes” in
Row 047, then Rows
048-050 become
required fields. If
you select “No” in
Row 047, then skip
to Row 051.

n/a

This is not a data entry field.

Change #31
Location: Page 20, Measure Score Level (Accountable Entity Level Testing)
Reason for Change: Removed Face Validity: Level of Analysis row
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

048

*Face Validity:

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.

Level of Analysis

For MIPS-Quality submissions, you must
report the results of individual clinicianlevel testing. If group-level testing is
available, you may submit those results
as an attachment.

CY 2024 Final Rule text: N/A
Change #32
Location: Page 20, Measure Score Level (Accountable Entity Level) Testing, Row 048
Reason for Change: Updated row number and Field Label.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

049

*Face validity:

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

Number of voting
experts and
patients/caregivers

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

048

*Face validity: Total
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

Numeric field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

poor quality care among accountable
entities).

Change #33
Location: Page 20, Measure Score Level (Accountable Entity Level) Testing, Row 049
Reason for Change: Updated row number and Field Label.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

050

*Face validity:

Indicate the number of experts and
patients/caregivers who voted in
agreement that the measure could
differentiate good from poor quality
care among accountable entities. If
votes were conducted using a scale,
sum all responses in agreement with
the statement. Do not include neutral
votes. If more than one question was
asked of the experts and
patients/caregivers, only provide
results from the question relating to the
ability of the final performance
measure to differentiate good from
poor quality care.

Numeric field

Result

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

049

*Face validity:

Numeric field

Number of experts
and
patients/caregivers
who voted in
agreement

Change #34
Location: Page 20, Measure Score Level (Accountable Entity Level) Testing, Row 050
Reason for Change: Updated row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level

051

Face validity:
Interpretation

Briefly explain the interpretation of the
result, including any disagreement with

Free text field

Subsection

Row

Field Label

(Accountable
Entity Level)
Testing

Guidance

ADD YOUR CONTENT HERE

the face validity of the performance
measure.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Score Level
(Accountable
Entity Level)
Testing

050

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 #35
Location: Page 21, Patient/Encounter Level (Data Element Level) Testing, Row 051
Reason for Change: Updated row number, Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

052

*Patient/Encounter

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.

☐ Yes
☐ No

Level Testing

• 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 PatientReported 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.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

051

*Patient/Encounter

☐ Yes
☐ No
☐ Not applicable

Level Testing

• Select “Yes” if data element
agreement was assessed at the
individual data element 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 PatientReported 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.
• Select “Not applicable” if the
measure relies entirely on
administrative data.

n/a

If you select “Yes”
in Row 051, then
Rows 052-056
become required
fields. If you select
“No” or “Not
applicable” in Row
051, then skip to
Row 057.

Note: This section includes tests of
both data element reliability and
validity.
n/a

This is not a data entry field.

Change #36
Location: Page 22, Patient/Encounter Level (Data Element Level) Testing, Row 052
Reason for Change: Updated row number and Guidance.
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/measurelifecycle/measure-testing/evaluationcriteria/scientificacceptability/reliability)

☐ Agreement between two manual reviewers
☐ Agreement between eCQM and manual reviewer
☐ Agreement between other gold standard and
manual reviewer

Note: This section refers to the
patient/encounter level data
elements in the final performance
measure. Refer to the PatientReported Data section for testing of
patient/encounter level data
elements in surveys or patient
reported tools.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

052

*Type of Analysis

Select all that apply. For more
information on patient/encounter
level testing, refer to the Blueprint
content on the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluationcriteria/scientificacceptability/reliability)

☐ Agreement between two manual reviewers
☐ Agreement between eCQM and manual reviewer
☐ Agreement between other gold standard and
manual reviewer

Change #37
Location: Page 22, Patient/Encounter Level (Data Element Level) Testing, Row 053
Reason for Change: Updated row number.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

054

*Sample Size

Indicate the number of
patients/encounters sampled.

Numeric field

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

053

*Sample Size

Indicate the number of
patients/encounters sampled.

Numeric field

Change #38
Location: Page 22, Patient/Encounter Level (Data Element Level) Testing, Row 054
Reason for Change: Updated row number and Guidance.
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

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

054

*Statistic Name

Select one. 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. Other statistics and results
should be provided in the
“Interpretation of results” field or
provided as an attachment.

☐ Percent agreement
☐ Kappa
☐ Correlation coefficient
☐ Sensitivity
☐ Positive Predictive Value

Change #39
Location: Page 23, Patient/Encounter Level (Data Element Level) Testing, Row 055
Reason for Change: Updated row number and Guidance.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

056

*Statistical Results:

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.

Numeric field

Individual Data
Element

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.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

055

*Statistical Results:

Indicate the single lowest critical data
element result of the statistic
selected above. This field is intended
to capture the least reliable or least
valid data element included in the
measure. Information about all
critical data elements should be
provided in the “Interpretation of
results” field.

Numeric field

Individual Data
Element

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%. The percent value should
be entered as a whole number; for
example, 70% would be entered as 70
and NOT 0.7.
If not tested at the individual data
element level, enter 9999.

Change #40
Location: Page 23, Patient/Encounter Level (Data Element Level) Testing
Reason for Change: Removed Statistical Results: Overall Denominator and Overall Numerator
rows.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

057

*Statistical Results:

Numeric field

Patient/Encounter
Level (Data
Element Level)
Testing

058

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.
Indicate the result for the overall
numerator of the statistic selected
above. If not tested at the numerator
level, enter 9999.

Overall
Denominator

*Statistical Results:

Overall Numerator

Numeric field

CY 2024 Final Rule text: N/A
Change #41
Location: Page 23, Patient/Encounter Level (Data Element Level) Testing, Row 056
Reason for Change: Update row number and Guidance.
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.

ADD YOUR CONTENT HERE

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.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient/Encounter
Level (Data
Element Level)
Testing

056

*Interpretation of

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, provide
the name of the attachment and
location in the attachment.

Free text field

results

Change #42
Location: Page 24-27, Patient-Reported Data and Measure Performance, Row 057-069
Reason for Change: Relocated Patient Reported Data and Measure Performance rows.
Removed and added new rows. Updated Guidance.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

PatientReported
Data

060

*Does the

Indicate whether the performance
measure utilizes data from structured
surveys or patient-reported tools.

☐ Yes
☐ No

n/a

This is not a data entry field.

PatientReported
Data

061

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.

ADD YOUR CONTENT HERE

performance
measure use survey
or patient-reported
data?
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 062.

*Surveys or

patient-reported
outcome tools

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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.

PatientReported
Data

062

*Survey level
testing

Indicate whether any of the surveys or
tools is proprietary requiring licenses or
fees for use.
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/measurelifecycle/measure-testing/evaluationcriteria/scientificacceptability/reliability).

☐ Yes
☐ No

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.

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.

Select “No” if any of the surveys or
tools included in the measure have not
been validated.
n/a

n/a

PatientReported
Data

063

*Type of testing
analysis

Select all that apply.

PatientReported
Data

064

*Testing

Briefly describe the method used to
psychometrically test or validate the
patient survey or patient-reported
outcome tool. (e.g., Cronbach’s alpha,
ICC, Pearson correlation coefficient,
Kuder-Richardson test). If the survey or
tool was developed prior to the
development of the performance
measure, describe how the intended
use of the survey or tools for the
performance measure aligns with the
survey or tool as originally designed and
tested. Indicate whether the measure
uses all components within a tool, or
only parts of the tool. Summarize the
statistical results and briefly describe
the interpretation of results.

methodology and
results

This is not a data entry field.

☐ Internal Consistency
☐ Construct Validity
☐ Other (enter here):
ADD YOUR CONTENT HERE

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Performance

065

*Measure
performance - type
of score

Select one

Measure
Performance

066

*Measure

Select one

n/a

Measure
Performance

067

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 068079 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 067 and 070079 become
required fields.

☐ Proportion
☐ Ratio
☐ Categorical (e.g., yes/no)
☐ Continuous variable (e.g., average)
☐ Other (enter here:)
☐ 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
This is not a data entry field

performance score
interpretation

*Passing score

Provide the value that indicates the
passing score for the performance
measure.

Numeric field

Please enter only one value in the
response field and do not enter a range
of values.
Measure
Performance

068

*Lower limit of

defined interval

If unknown or not available, enter 9999.
Provide the lower limit for the
performance score’s defined interval.

Numeric field

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.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Performance

069

*Upper limit of
defined interval

Provide the upper limit for the
performance score’s defined interval.

Numeric field

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.
Measure
Performance

070

*Number of

accountable entities
included in analysis

If unknown or not available, enter 9999.
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."

Numeric field

Please enter a single value and do not
enter a range.
Measure
Performance

071

Measure
Performance

072

*Number of

accountable
entities: unit

*Overall mean
performance score

If unknown or not available, enter 9999.
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."
Provide the mean performance score
across accountable entities in the test
sample that is relevant to the intended
use of the measure.

ADD YOUR CONTENT HERE

Numeric field

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.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Performance

073

*50th percentile
(median)

Provide the median performance score
(50th percentile) for the testing sample
that is relevant to the intended use of
the measure.

Numeric field

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.

Measure
Performance

074

*Minimum

performance score

If a median performance score is not
available, enter 9999.
Provide the minimum performance
score for the testing sample that is
relevant to the intended use of the
measure.

Numeric field

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.

Measure
Performance

075

10th percentile

If a minimum performance score is not
available, enter 9999.
Provide the performance score at the
10th percentile for the testing sample
that is relevant to the intended use of
the measure.

Numeric field

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.

Measure
Performance

076

90th percentile

If a 10th percentile performance score
is not available, enter 9999.
Provide the performance score at the
90th percentile for the testing sample
that is relevant to the intended use of
the measure.

Numeric field

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.

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.

Numeric field

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.

Measure
Performance

078

Measure
Performance

079

*Overall standard

deviation of
performance scores

*Is there evidence
for statistically
significant gaps in
measure score
performance among
select
subpopulations of
interest defined by
one or more social
risk factors?

If a maximum performance score is not
available, enter 9999.
Provide the standard deviation of
performance scores for the testing
sample that is relevant to the intended
use of the measure.
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.

Numeric field

☐ Yes
☐ No
☒ Not tested

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

PatientReported
Data

057

*Does the

Indicate whether the performance
measure utilizes data from structured
surveys or patient-reported tools.

☐ Yes
☐ No

n/a

This is not a data entry field.

PatientReported
Data

058

List each survey or patient-reported
outcome tool accepted by the
performance measure. 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.

Free text field

performance
measure use survey
or patient-reported
data?
If you select “Yes”
in Row 057, then
Rows 058 and 059
become required
fields. If you select
“No” in Row 057,
then skip to Row
060.

*Survey level

testing
methodology and
results

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.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Indicate whether any of the surveys or
tools is proprietary requiring licenses
or fees for use.

PatientReported
Data

059

Measure
Performance

060

Measure
Performance

061

Measure
Performance

062

*Spanish

development of the
survey instrument.

Briefly describe the method used to
psychometrically test or validate the
patient survey or patient-reported
outcome tool. (e.g., Cronbach’s alpha,
ICC, Pearson correlation coefficient,
Kuder-Richardson test). If the survey or
tool was developed prior to the
development of the performance
measure, describe how the intended
use of the survey or tools for the
performance measure aligns with the
survey or tool as originally designed
and tested. Indicate whether the
measure uses all components within a
tool, or only parts of the tool.
Summarize the statistical results and
briefly describe the interpretation of
results.
Select all that apply. Survey
instruments are expected to be
developed in Spanish, in addition to
English.

*Measure

performance - type
of score

Select one. Measure performance
score type should be at the level of
accountable entity.

*Measure

Select one

*Number of

Provide the number of accountable
entities included in the analysis of the
distribution of performance scores.

performance score
interpretation

accountable
entities included in
analysis

☐ Survey instrument was developed in Spanish and
validated
☐ Survey instrument was developed in Spanish but not
yet validated
☐ Working on Spanish version of survey instrument
☐ There are no plans to develop a Spanish version of
survey instrument
☐ Categorical (e.g., measured entity scores yes/no,
pass/fail, or rating scale/score)
☐ Composite scale/non-weighted score
☐ Composite scale/weighted score
☐ Continuous variable (e.g., average)
☐ Count
☐ Frequency Distribution
☐ Proportion
☐ Rate
☐ Ratio
☐ 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
Numeric field

Please enter a single value and do not
enter a range.
If unknown or not available, enter
9999.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Measure
Performance

063

*Number of
accountable
entities: unit

Provide the unit of accountable
entities included in the analysis of the
distribution of performance scores.

Free text field

Measure
Performance

064

*Number of

Numeric field

Measure
Performance

065

Provide the number of persons
included in the analysis of the
distribution of performance scores
Provide the performance score at the
10th percentile for the testing sample
that is relevant to the intended use of
the measure.

persons

*10th percentile

Numeric field

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.

Measure
Performance

066

*50th percentile

(median)

If a 10th percentile performance score
is not available, enter 9999.
Provide the median performance score
(50th percentile) for the testing sample
that is relevant to the intended use of
the measure.

Numeric field

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.

Measure
Performance

067

*90th percentile

If a median performance score is not
available, enter 9999.
Provide the performance score at the
90th percentile for the testing sample
that is relevant to the intended use of
the measure.

Numeric field

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.

Measure
Performance

068

*Additional

measure
performance
information

If a 90th percentile performance score
is not available, enter 9999.
Provide the following additional
measure performance information, as
applicable:

Free text field

- Mean performance score across
accountable entities in the test sample

Subsection

Measure
Performance

Row

069

Field Label

*Is there evidence

for statistically
significant gaps in
measure score
performance
among select
subpopulations of
interest defined by
one or more social
risk factors?

Guidance
that is relevant to the intended use of
the measure.
- Minimum and maximum
performance score for the testing
sample that is relevant to the intended
use of the measure.
- Standard deviation of performance
scores for the testing sample that is
relevant to the intended use of the
measure.
- Passing score for the performance
measure.
- Performance score’s defined interval,
including upper and lower limit of the
performance score.
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.

ADD YOUR CONTENT HERE

☐ Yes
☐ No
☐ Not tested

Change #43
Location: Page 28, Importance, Row 070-072
Reason for Change: Relocated Importance rows. Removed and added new rows. Updated
Guidance.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Importance

080

*Meaningful to

Select one. Input from patients and/or
caregivers can include any of the
following:
• Patients
• Primary caregivers
• Family
• Other relatives

☐ Yes
☐ No

*Denominator:

Indicate the total number of
patients/caregivers who responded.

Numeric field

Importance

081

Patients. Was input
on the final
performance
measure collected
from patients
and/or caregivers?
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

Subsection

Importance

Row

082

083

Field Label

Guidance

ADD YOUR CONTENT HERE

*Numerator: Total

Indicate the total number of
patients/caregivers who agreed.

Numeric field

*Were the

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:

☐ Yes
☐ No

patients in similar
situations or with
similar conditions.

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.
measured entities
(or others)
consulted on the
final performance
measure to assess
whether the
measure is easy to
understand AND is
useful for decisionmaking?

n/a

Importance

084

If you select “Yes” in
Row 083, then Rows
084-085 become
required fields. If
you select “No” in
Row 083, then skip
to Row 086.

*Denominator:

Total number of
measured entities
(or others) who
responded when
asked if information
produced by the
performance
measure is easy to
understand AND

• 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 decisionmaking.
n/a

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 decisionmaking.

This is not a data entry field.

Numeric field

Notes:
• This is separate from any face validity
testing.
• The assessment of understandability
and decision-making utility of the

Subsection

Importance

Row

085

Field Label

Guidance

useful for decisionmaking

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 decisionmaking.
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.

*Numerator: Total

number of
measured entities
(or others) who
agreed that
information
produced by the
performance
measure is easy to
understand AND
useful for decisionmaking

Importance

086

*Estimated impact

of the measure:
Estimate of annual
denominator size

Importance

087

*Estimated impact
of the measure:
Estimate of annual
denominator size:
unit

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 decisionmaking.
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.
Indicate the unit (e.g., patients) of the
estimate of annual denominator size.

ADD YOUR CONTENT HERE

Numeric field

Free text field

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Importance

070

*Meaningful to

Select one. Patients and/or caregivers
can include any of the following:
• Patients
• Primary caregivers
• Family
• Other relatives

☐ Yes
☐ No
☐ Not evaluated

n/a

This is not a data entry field.

Describe the input collected from
patient/caregivers consulted about the
measure, including the number of
patients/caregivers consulted and the
number who agreed that the measure
is meaningful and produces information
that is valuable in making care
decisions.
Describe the input collected from
measured entities, or others such as
consumers, purchasers, policy makers,
etc., using any of the following
methods:

Free text field

n/a

Importance

071

Patients. Did the
majority of
patients/caregivers
consulted agree
that the measure is
meaningful and/or
produces
information that is
valuable to them in
making their care
decisions?
If you select “Yes” in
Row 070, then Row
071 becomes a
required field. If you
select “No” or “Not
evaluated” in Row
070, then skip to
Row 072.

*Description of

input collected from
patients/caregivers
consulted

Importance

072

Description of input
collected from
measured entities.

Free text field

• Focus groups
• Structured interviews
• Surveys of potential users
Notes:
• This is separate from face validity
testing of the performance measure.

Change #44
Location: Page 29, Background Information, Row 073
Reason for Change: Updated row number, Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Background
Information

088

*What is the

Select one

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 this field, then
skip to "What data
sources are used for
the measure?". 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 "Range of
year(s) this measure
has been used by
CMS Program(s)"
through "How will
this measure align
with the same
measure(s) that are
currently used in
other federal
programs?" become
required fields.

n/a

☐ New measure never previously submitted to the
MUC List, 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
This is not a data entry field.

history or
background for
including this
measure on the
current year MUC
List?

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Background
Information

073

*What is the
history or
background for
including this
measure on the
current year MUC
List?

Select one

n/a

If you select “New
measure never
reviewed by
Measure
Applications
Partnership (MAP)
Workgroup, or PreRulemaking
Measure Review
(PRMR) or used in a
CMS Program” in
Row 073, then skip
to Row 078. If you
select “Measure
currently used in a
CMS program being
submitted without
substantive changes
for a new or
different program”
or “Measure
currently used in a
CMS program, but
the measure is
undergoing
substantial change”
then Rows 074-077
become required
fields.

n/a

☐ New measure never reviewed by Measure
Applications Partnership (MAP) Workgroup, or PreRulemaking Measure Review (PRMR) or used in a
CMS program
☐ Submitted previously but not included in MUC List
☐ Measure previously submitted to MAP or PRMR,
refined, and resubmitted per MAP or PRMR
recommendation
☐ Measure currently used in a CMS program being
submitted without substantive changes for a new or
different program
☐ Measure currently used in a CMS program, but the
measure is undergoing substantive change
This is not a data entry field.

Note:
•
“CMS program” in the response
options refers only to the
Medicare programs that undergo
the Pre-Rulemaking process. A full
list of these programs can be
found on the CMS Program
Measure Needs and Priorities
report.

Change #45
Location: Page 29-31, Background Information, Row 074-076
Reason for Change: Relocated Background Information rows. Updated Field Label, Guidance,
selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Background
Information

097

*Range of year(s)

For example: Hospice Quality Reporting
(2012-2018)

ADD YOUR CONTENT HERE

Background
Information

098

*What other

Select all that apply. These should be
current use programs only, not
programs for the upcoming year’s
submittal.

☐ Ambulatory Surgical Center Quality Reporting
Program
☐ End-Stage Renal Disease (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 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
☐ Part C & D Star Rating [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
☐ Other (enter here):

this measure has
been used by CMS
Program(s).
federal programs
are currently using
this measure?

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.

ADD YOUR CONTENT HERE

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.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Background
Information

074

*Range of year(s)

Example: Hospice Quality Reporting
(2012-2018)

Free text field

Background
Information

075

*What other

Select all that apply. These should be
current use programs only, not
programs for the upcoming year’s
submittal.

☐ Ambulatory Surgical Center Quality Reporting
Program
☐ End-Stage Renal Disease (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 Hospital Quality Reporting Program
☐ Medicare Promoting Interoperability Program
☐ Medicare Shared Savings Program
☐ Merit-based Incentive Payment System-Cost
☐ Merit-based Incentive Payment System-Quality
☐ Part C Star Rating
☐ Part D Star Rating
☐ Prospective Payment System-Exempt Cancer
Hospital Quality Reporting Program
☐ Rural Emergency Hospital Quality Reporting Program
☐ Skilled Nursing Facility Quality Reporting Program

this measure has
been used by CMS
Program(s).
federal programs
are currently using
this measure?

Background
Information

076

*How will this

measure align with
the same
measure(s) that are
currently used in
other federal
programs?

☐ Skilled Nursing Facility Value-Based Purchasing
Program
☐ Other (enter here):
Free text field

Change #46
Location: Page 31, Background Information, Row 077
Reason for Change: Relocated rows and subsections from Previous Measures to Background
Information. Updated Field Label, Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

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

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Background
Information

077

*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.

Free text field

Change #47
Location: Page 31-33, Previous Measures, Row 078-085
Reason for Change: Relocated Previous Measures rows. Updated Field Label, Guidance,
selection options, and skip logic. Added row 085
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Previous
Measures

089

*Was this measure

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

*In what prior

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.

*What was the

List both the year and the associated
MUC ID number in each year. If
unknown, enter N/A.

☐ 2011
☐ 2012
☐ 2013
☐ 2014
☐ 2015
☐ 2016
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ Other (enter here):
ADD YOUR CONTENT HERE

*List the CMS CBE

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."
List both the year and the associated
CMS programs in each year.

ADD YOUR CONTENT HERE

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

published on a
previous year's
Measures Under
Consideration list?

Previous
Measures

090

Previous
Measures

091

Previous
Measures

092

Previous
Measures

093

Previous
Measures

094

If you select “Yes” in
Row 089, then Rows
90-97 become
required fields. If
you select “No” in
Row 089, then skip
to Row 98.
year(s) was this
measure published
on the Measures
Under
Consideration List?

MUC ID for the
measure in each
year?

MAP workgroup(s)
in each year

*What were the
programs that MAP
reviewed the
measure for in each
year?
*What was the

MAP
recommendation in
each year?

ADD YOUR CONTENT HERE

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Previous
Measures

095

Briefly describe the reason(s) if known.

ADD YOUR CONTENT HERE

Previous
Measures

096

*Why was the
measure not
recommended by
the MAP
workgroups in those
year(s)?

List both the year and the associated
MAP report page number for each year.

ADD YOUR CONTENT HERE

*MAP report page

number being
referenced for each
year

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Previous
Measures

078

*Was this measure

☐ Yes
☐ No

n/a

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.
n/a

Previous
Measures

079

*In what prior
year(s) was this
measure published
on the Measures
Under
Consideration List?

Previous
Measures

080

*What was the

List both the year and the associated
MUC ID number in each year. If
unknown, enter N/A.

Previous
Measures

081

*List the CMS CBE

Previous
Measures

082

List both the year and the associated
workgroup name in each year. MAP and
PRMR workgroup options include:
Clinician; Hospital; Post-Acute
Care/Long-Term Care; Coordinating
Committee. Example: “Clinician, 2014.”
List both the year and the associated
CMS programs in each year.

published on a
previous year’s
Measures Under
Consideration List?

If you select “Yes” in
Row 078, then Rows
079-085 become
required fields. If
you select “No” in
Row 078, then skip
to Row 086.

MUC ID for the
measure in each
year?

workgroup(s) (MAP
or PRMR) in each
year

*What were the
programs that MAP
or PRMR reviewed
the measure for in
each year?

This is not a data entry field.

☐ 2011
☐ 2012
☐ 2013
☐ 2014
☐ 2015
☐ 2016
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
Free text field

Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Previous
Measures

083

*What was the
MAP or PRMR
recommendation in
each year?

Free text field

Previous
Measures

084

Previous
Measures

085

*Why was the
measure not
recommended by
the MAP or PRMR
workgroups in those
year(s)?

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.
Briefly describe the reason(s) if known.

List both the year and the associated
MAP report page number for each year.

Free text field

*MAP or PRMR

report page number
being referenced
for each year

Free text field

Change #48
Location: Page 34, Data Sources, Row 086
Reason for Change: Updated row number, Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Data Sources

101

*What data sources

Select all that apply.

☐ Administrative Data (non-claims)
☐ Claims Data
☐ Electronic Clinical Data (non-EHR)
☐ Electronic Health Record
☐ Paper Medical Records
☐ Standardized Patient Assessments
☐ Patient Reported Data and Surveys
☐ Registries
☐ Other (enter here):

are used for the
measure?

Use the next field to specify or
elaborate on the type of data source, if
needed to define your measure.

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

Data
Sources

086

*What data sources
are used for the
measure?

Select all that apply.
For example, if the measure uses survey
data that are captured both
electronically and in paper format,
select the “Applications: PatientReported Health Data or Survey Data
(electronic)” from the “Digital Data
Sources” category and “PatientReported Health Data or Survey Data
(telephonic or paper-based)” from the
“Non-Digital Data Sources” category.
For more information about digital data
sources, please refer to the “Digital
Data Sources” section of the “dQMs Digital Quality Measures” webpage on
the eCQI Resource Center available at:
https://ecqi.healthit.gov/dqm?qttabs_dqm=1

ADD YOUR CONTENT HERE
☐ Digital-Administrative systems: Administrative Data
(non-claims)
☐ Digital-Administrative systems: Claims Data
☐ Digital-Applications: Patient-Generated Health Data
(e.g., home blood pressure monitoring)
☐ Digital-Applications: Patient-Reported Health Data or
Survey Data (electronic)
☐ Digital-Case Management Systems
☐ Digital-Clinical Registries
☐ Digital-Electronic Clinical Data (non-EHR) or Social
Needs Assessments
☐ Digital-Electronic Health Record (EHR) Data
☐ Digital-Health Information Exchanges (HIE) Data
☐ Digital-Instrument Data (e.g., medical devices and
wearables)
☐ Digital-Laboratory Systems Data
☐ Digital-Patient Portal Data
☐ Digital-Prescription Drug Monitoring Program Data

Subsection

n/a

Row

n/a

Field Label

If your selections in
Row 086 only
include digital data
sources, then skip to
Row 089.
Otherwise, Row 087
becomes a required
field.

Guidance

ADD YOUR CONTENT HERE

n/a

☐ Digital-Standardized Patient Assessment Data
(electronic)
☐ Digital-Other (enter here):
☐ Non-Digital-Paper Medical Records
☐ Non-Digital-Standardized Patient Assessments
(paper-based)
☐ Non-Digital-Patient-Reported Health Data or Survey
Data (telephonic or paper-based)
☐ Non-Digital-Other (enter here):
This is not a data entry field.

Change #49
Location: Page 34-35, Data Sources, Row 087 and 088
Reason for Change: Added new rows for Digital Data Sources and Digital Format.
CY 2023 Final Rule text: N/A
CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Data Sources

087

*Measure version
that uses only
digital data sources

Select one. Indicate whether there is a
version of the measure that uses only
digital data sources.

☐ Yes
☐ No

n/a

This is not a data entry field.

Data Sources

088

If you select “Yes” in
Row 087, then skip
to Row 089.
Otherwise, Row 088
becomes a required
field.

Select one. Indicate whether there is a
viable path for the measure to be
transitioned to an exclusively digital
format.

☐ Yes
☐ No

*Path to Digital

Format

Change #50
Location: Page 35, Data Sources
Reason for Change: Removed rows.
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

Select “Yes” if measure data sources
include at least one of the following:
• Administrative Claims
• Administrative Data

☐ Yes
☐ No

Subsection

Row

Field Label

Guidance

at least one digital
data source.

• Patient Assessment Instrument (e.g.,
MDS, LTCH-CARE, OASIS)
• EHR
• Registry (e.g., QCDR and Qualified
Registry and EQRS)

Data Sources

103

If applicable, specify
the data source

Data Sources

104

Description of parts
related to each data
source

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
Use this field to specify or elaborate on
the type of data source, if needed, to
define your measure.
Describe the parts or elements of the
measure that are relevant to the
selected data sources

ADD YOUR CONTENT HERE

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

CY 2024 Final Rule text: N/A
Change #51
Location: Page 36, Steward Information, Row 089 and 090
Reason for Change: Updated row numbers, Guidance, and selection options.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Steward
Information

105

*Measure Steward

Enter the current Measure Steward.

See Appendix A.084-086 for list choices.
Copy/paste or enter your choices here:

Steward
Information

106

*Measure Steward

Please provide the contact information
of the measure steward.

ADD YOUR CONTENT HERE

Contact Information

CY 2024 Final Rule text:

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Steward
Information

089

*Measure Steward

See Appendix A.085 for list choices.
Copy/paste or enter your choices here:

Steward
Information

090

*Measure Steward

Enter the current Measure Steward.
Typically, this is an organization or
other agency/institution/entity name.
Please provide the contact information
of the measure steward.

Contact Information

ADD YOUR CONTENT HERE

Change #52
Location: Page 36, Long-Term Steward Information, Row 091 and 092
Reason for Change: Updated row numbers, Field Labels, Guidance, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Long-Term
Steward
Information

107

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:

If different from Steward above, enter
the required contact information for
the Long-Term Measure Steward listed
above

ADD YOUR CONTENT HERE

Long-Term
Steward
Information

108

If you identify a
different Measure
Steward then
complete row 108, if
the Measure
Steward and LongTerm Measure
Steward are the
same then skip to
row 109
Long-Term Measure
Steward Contact
Information

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Long-Term
Steward
Information

091

*Is the long-term

☐ Yes
☐ No

n/a

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.
n/a

Long-Term
Steward
Information

092

If different from Steward above, enter
the required contact information for
the Long-Term Measure Steward listed
above

ADD YOUR CONTENT HERE

steward different
than the steward?

If you select “Yes” in
Row 091, then Row
092 becomes a
required field. If you
select “No” in Row
091, then skip to
Row 093.

*Long-Term

Measure Steward
Contact Information

This is not a data entry field.

Change #53
Location: Page 36-37, Submitter Information, Row 093 and 095
Reason for Change: Updated row numbers and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Submitter
Information

109

Select “Yes” or “No.”

☐ Yes
☐ No

Submitter
Information

110

Is primary submitter
the same as
steward?

*Primary Submitter
Contact Information

ADD YOUR CONTENT HERE

Submitter
Information

111

Secondary
Submitter Contact
Information

If different from Steward above: Last
name, First name; Affiliation;
Telephone number; Email address.
NOTE: The primary and secondary
submitters entered here do not
automatically have read/write/change
access to modify this measure in CMS
MERIT. To request such access for
others, when logged into the CMS
MERIT interface, navigate to “About”
and “Contact Us,” and indicate the
name and e-mail address of the
person(s) to be added.
If different from name(s) above: Last
name, First name; Affiliation;
Telephone number; Email address.

ADD YOUR CONTENT HERE

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Submitter
Information

093

Select “Yes” or “No.”

☐ Yes
☐ No

n/a

This is not a data entry field.

Submitter
Information

094

Is primary submitter
the same as
steward?
If you select “No” in
Row 093, then Row
094 becomes a
required field. If you
select “Yes” in Row
093, then skip to
Row 095.

*Primary Submitter
Contact Information

ADD YOUR CONTENT HERE

Submitter
Information

095

Secondary
Submitter Contact
Information

ADD YOUR CONTENT HERE

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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 #54
Location: Page 37-38, General Characteristics, Row 096-104
Reason for Change: Updated row numbers, Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

General
Characteristi
cs

112

*Measure Type

Select only one type of measure. For
definitions, see:
https://mmshub.cms.gov/aboutquality/new-to-measures/types.

☐ Cost/Resource Use
☐ Efficiency
☐ Intermediate Outcome
☐ Outcome
☐ PRO-PM or Experience of Care
☐ Process
☐ Structure

n/a

This is not a data entry field.

General
Characteristi
cs

113

If you select “PROPM or Experience of
Care” in row 112,
then row 113
becomes a required
field. If you select
“Outcome” or “PROPM or Experience of
Care in Row 112
then Row 147 in the
Evidence section
becomes a required
field.

*Assessment of

Select one. Indicate whether this
measure assesses patient experience of
care.

☐ Yes
☐ No

General
Characteristi
cs

114

*Is this measure in
the CMS Measures
Inventory Tool
(CMIT)?

Select Yes or No. Current measures can
be found at
https://cmit.cms.gov/CMIT_public/List
Measures

☐ Yes
☐ No

n/a

This is not a data entry field.

General
Characteristi
cs

115

If you select “Yes” in
Row 113 then Row
114 becomes a
required field.

*CMIT ID

If the measure is currently in CMIT,
enter the CMIT ID in the format #####X-XXXXXXX. Current measures and CMIT
IDs can be found at
https://cmit.cms.gov/CMIT_public/List
Measures

ADD YOUR CONTENT HERE

General
Characteristi
cs

116

Alternate Measure
ID

This is an alphanumeric identifier (if
applicable), such as a recognized
program ID number for this measure

ADD YOUR CONTENT HERE

patient experience
of care

Subsection

Row

Field Label

General
Characteristi
cs

117

*What is the target
population of the
measure?

General
Characteristi
cs

118

*What one area of

General
Characteristi
cs

119

General
Characteristi
cs

120

specialty the
measure is aimed
to, or which
specialty is most
likely to report this
measure?

*Evidence of
performance gap

*Unintended
consequences

Guidance
(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.
What populations are included in this
measure? e.g., Medicare Fee for
Service, Medicare Advantage, Medicaid,
Children’s Health Insurance Program
(CHIP), All Payer, etc.
Select the ONE most applicable area of
specialty.

Evidence of a performance gap among
the units of analysis in which the
measure will be implemented. Provide
analytic evidence that the units of
analysis have room for improvement
and, therefore, that the
implementation of the measure would
be meaningful.
If you have lengthy text add the
evidence as an attachment, named to
clearly indicate the related form field.
Summary of potential unintended
consequences if the measure is
implemented. Information can be taken
from the CMS consensus-based entity
Consensus Development Process (CDP)
manuscripts or documents. If
referencing CDP documents, you must
submit the document or a link to the
document, and the page being
referenced.

ADD YOUR CONTENT HERE

See Appendix A.097 for list choices. Copy/paste or
enter your choice(s) here:

ADD YOUR CONTENT HERE

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

General
Characteristi
cs

096

*Measure Type

Select only one type of measure. For
definitions, see:
https://mmshub.cms.gov/aboutquality/new-to-measures/types.

n/a

If you select “PROPM or Patient
Experience of Care”
in Row 096, then
Row 097 and Row
122 become
required fields. If
not, then skip to

n/a

☐ Cost/Resource Use
☐ Efficiency
☐ Intermediate Outcome
☐ Outcome
☐ PRO-PM or Patient Experience of Care
☐ Process
☐ Structure
This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

*Assessment of

Select one. Indicate whether this
measure assesses patient experience of
care.

☐ Yes
☐ No

*Is this measure in

Select Yes or No. Current measures can
be found at
https://cmit.cms.gov/cmit/#/MeasureIn
ventory

☐ Yes
☐ No

If you select “Yes” in
Row 098, then Row
099 becomes a
required field. If you
select “No” in Row
098, then skip to
Row 100.

n/a

This is not a data entry field.

*CMIT ID

If the measure is currently in CMIT,
enter the CMIT ID in the format #######-X-PRGM. Current measures and
CMIT IDs can be found at
https://cmit.cms.gov/cmit/#/MeasureIn
ventory

ADD YOUR CONTENT HERE

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.
What populations are included in this
measure? E.g., Medicare Fee for
Service, Medicare Advantage, Medicaid,
Children’s Health Insurance Program
(CHIP), All Payer, etc.
Select the ONE most applicable area of
specialty.

ADD YOUR CONTENT HERE

Free text field

Row 098. If you
select “Outcome” in
Row 096, then Row
122 becomes a
required field.
General
Characteristi
cs

097

General
Characteristi
cs

098

n/a

General
Characteristi
cs

099

General
Characteristi
cs

100

Alternate Measure
ID

General
Characteristi
cs

101

*What is the target
population of the
measure?

General
Characteristi
cs

102

*What one area of

General
Characteristi
cs

103

patient experience
of care
the CMS Measures
Inventory Tool
(CMIT)?

specialty the
measure is aimed
to, or which
specialty is most
likely to report this
measure?

*Evidence of
performance gap

Free text field

See Appendix A.098 for list choices. Copy/paste or
enter your choice(s) here:

If you have lengthy text add the
evidence as an attachment, named to
clearly indicate the related form field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

General
Characteristi
cs

104

*Unintended
consequences

Summary of potential unintended
consequences if the measure is
implemented. Information can be taken
from the CMS consensus-based entity
Consensus Development Process (CDP)
manuscripts or documents. If
referencing CDP documents, you must
submit the document or a link to the
document, and the page being
referenced.

Free text field

Change #55
Location: Page 39-45, Evidence, Row 105-122
Reason for Change: Updated Evidence row numbers. Removed and added rows. Updated
Guidance, selection options, and skip logic
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Evidence

121

*Type of evidence

Select all that apply. Refer to the latest
CMS Blueprint version
(https://mmshub.cms.gov/measurelifecycle/measureconceptualization/informationgathering-overview) and the
supplementary material related to
evidence review
(https://mmshub.cms.gov/sites/default
/files/Environmental-Scans.pdf) to
obtain updated guidance.
n/a

☐ Clinical Guidelines or USPSTF (U.S. Preventive
Services Task Force) Guidelines
☐ Peer-Reviewed Systematic Review
☐ Empirical data
☐ Grey Literature

Enter a numerical value of ≥1. Count all
guidelines that are relevant to this

Numeric field

to support the
measure

n/a

Evidence

122

If you select
“Clinical Guidelines
or USPSTF (U.S.
Preventive Services
Task Force)
Guidelines in Row
121, then Rows 122129 become
required fields. If
you select
“Systematic
Review” in Row 121,
then Rows 137-141
become required
fields. If you select
“Empirical data” in
Row 121, then Rows
142-144 become
required fields. If
you select “Grey
Literature” in Row
121, then Rows 145147 become
required fields.

*Number of clinical

guidelines, including
USPSTF guidelines

This is not a data entry field.

Subsection

Evidence

Row

123

Field Label

Guidance

that address this
topic

measure topic including those that
offer contradictory guidance.
Provide a detailed description of which
guideline(s) support the measure and
indicate for each, whether they are
evidence-based or consensus-based.

*Outline the clinical

guideline(s)
supporting this
measure

ADD YOUR CONTENT HERE

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 PROPM, 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/measurelifecycle/measureconceptualization/informationgathering-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.

Subsection

Row

Field Label

Guidance

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.

ADD YOUR CONTENT HERE

Evidence

125

*Publication year

Evidence

126

*Guideline citation

Evidence

127

*Is this an
evidence-based
clinical guideline

Evidence

128

*Does the clinical
guideline include a
publicly available
evidence summary?

Evidence

129

*List the guideline

statement that
most closely aligns
with the measure
concept.

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)
Provide the publication year for the
primary clinical guideline.
Use the 4-digit format (e.g., 2016).
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
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 (nonsystematic).
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.
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

Numeric field (4-digit year)
☐ Citation (enter here)
☐ URL (enter here)
☐ DOI (enter here)
☐ Not available

☐ Yes
☐ No

☐ Yes (enter URL here:)
☐ No

ADD YOUR CONTENT HERE

Subsection

Row

Field Label

Evidence

130

*Is the guideline
graded?

n/a

Evidence

131

If you select “Yes” in
Row 130, then Rows
131-136 become
required fields.

Evidence

132

133

Guidance
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.
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.

ADD YOUR CONTENT HERE

☐ Yes
☐ No

Select one.
n/a

This is not a data entry field.

*What evidence

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)

*List all categories

Insert the complete list of grading
categories and their definitions.

ADD YOUR CONTENT HERE

*For the guideline

Select the associated strength of
recommendation using the convention
used by the guideline developer.

☐ 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
☐ Yes
☐ No

grading system did
the guideline use to
describe strength of
recommendation?
and corresponding
definitions for the
evidence grading
system used to
describe strength of
recommendation in
the guideline.
statement that
most closely aligns
with the measure
concept, what is the
associated strength
of
recommendation?

Evidence

134

*Is the selected
guideline statement
used to support an
inappropriate
use/care measure?

Evidence

135

*List all categories
and corresponding
definitions for the
evidence grading
system used to

Select one.

Select one. Indicate whether the
guideline statement mentioned in "List
the guideline statement that most
closely aligns with the measure
concept" (row 126) is used to promote
the practice of not performing a specific
action, process or intervention to
support an inappropriate use or
inappropriate care measure.
Insert the complete list of grading
categories and their definitions.

ADD YOUR CONTENT HERE

Subsection

Evidence

Row

136

137

138

Field Label
describe level of
evidence or level of
certainty in the
evidence?

*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?
*Number of
systematic reviews
that inform this
measure concept

*Briefly summarize

the peer-reviewed
systematic review(s)
that inform this
measure concept

Evidence

139

*Peer-reviewed

systematic review
citation

Guidance

ADD YOUR CONTENT HERE

Select the associated level of evidence
or certainty of evidence using the
convention used by the guideline
developer.

☐ High or similar
☐ Moderate or similar
☐ Low, Very Low or similar
☐ Other (enter here)

Select one.

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.
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.
If more than one article was identified,
provide at least one of the following for
one key article:
• Citation
• URL
• DOI

Numeric field

ADD YOUR CONTENT HERE

☐ Citation (enter here:)
☐ URL (enter here:):
☐ DOI (enter here:)
☐ Not available

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Evidence

140

*Peer-reviewed

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.
If more than one article was identified,
provide at least one of the following for
one key article:
• Citation
• URL
• DOI

☐ Yes (please provide search strategy in an
attachment; e.g., years searched, keywords and search
terms used, databases used, etc.)
☐ No

original research

Evidence

141

*Peer-reviewed

original research
citation

Evidence

142

*Source of
empirical data

Evidence

143

*Summarize the
empirical data

Evidence

144

*Empirical data

citation

Evidence

145

*Name grey
literature

Evidence

146

*Summarize the

grey literature

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.
Select all that apply

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.
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.
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.
Provide a summary of the other type(s)
of evidence 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.

☐ Citation (enter here:)
☐ URL (enter here:):
☐ DOI (enter here:)
☐ Not available

☐ Peer-reviewed narrative literature review
☐ Published and publicly available reports (e.g., from
agencies)
☐ Internal data analysis
☐ Other (enter here)
ADD YOUR CONTENT HERE

☐ Citation (enter here:)
☐ URL (enter here:):
☐ DOI (enter here:)
☐ Not available

ADD YOUR CONTENT HERE

Subsection

Evidence

Row

147

Evidence

148

Field Label

*Grey literature
citation

*Does the evidence

discuss a
relationship
between at least
one process,
structure, or
intervention with
the outcome?

Guidance

ADD YOUR CONTENT HERE

If there is lengthy text, include details in
a separate evidence attachment.
If more than one piece of evidence was
identified, provide at least one of the
following for one key piece of evidence:
• Citation
• URL
• DOI

☐ Citation (enter here:)
☐ URL (enter here:):
☐ DOI (enter here:)
☐ Not available

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.
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

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Evidence

105

*Type of evidence

Select all that apply. Refer to the
Blueprint content on the CMS MMS
Hub
(https://mmshub.cms.gov/measurelifecycle/measureconceptualization/informationgathering-overview) and the
Environmental Scan supplemental
material
(https://mmshub.cms.gov/tools-andresources/mms-supplementalmaterials) to obtain updated guidance.
n/a

☐ Clinical Guidelines or USPSTF (U.S. Preventive
Services Task Force) Guidelines
☐ Peer-Reviewed Systematic Review
☐ Peer-Reviewed Original Research
☐ Empirical data
☐ Grey Literature

to support the
measure

n/a

If you select
“Clinical Guidelines
or USPSTF (U.S.
Preventive Services
Task Force)
Guidelines” in Row
105, then Rows 106113 become
required fields. If
you select “PeerReviewed
Systematic Review”
in Row 105, then
Rows 114 and 115
become required
fields. If you select
“Peer-Reviewed
Original Research”
in Row 105, then
Rows 116 and 117
become required
fields. If you select
“Empirical data” in

This is not a data entry field.

Subsection

Evidence

Row

106

Field Label
Row 105, then Rows
118 and 119
become required
fields. If you select
“Grey Literature” in
Row 105, then Rows
120 and 121
become required
fields.

*Outline the clinical

guideline(s)
supporting this
measure

Guidance

ADD YOUR CONTENT HERE

Provide a detailed description of which
guideline(s) support the measure and
indicate for each, whether they are
evidence-based or consensus-based.

Free text field

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 PROPM, 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 the Information Gathering
Overview on the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measureconceptualization/informationgathering-overview) and the

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Environmental Scan supplemental
material section addressing evidence
review (https://mmshub.cms.gov/toolsand-resources/mms-supplementalmaterials).

Evidence

107

*Guideline citation

Evidence

108

*List the guideline

statement that
most closely aligns
with the measure
concept.

Evidence

109

*Is the guideline
graded?

n/a

Evidence

110

If you select “Yes” in
Row 109, then Rows
110-111, and 113
become required
fields.

*List evidence
grading system used
and all categories
and corresponding
definitions for the
evidence grading
system used to
describe strength of
recommendation in
the guideline.

If there is lengthy text, describe the
guidelines in an evidence attachment.
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
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.
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.
n/a

Insert the complete list of evidence
grading systems, grading categories,
and category definitions used by the
clinical guideline (e.g., GRADE or
USPSTF) to describe the guideline
statement’s strength of
recommendation.

☐ Citation (enter here)
☐ URL (enter here)
☐ DOI (enter here)
☐ Not available

Free text field

☐ Yes
☐ No

This is not a data entry field.

Free text field

If there is lengthy text, include details in
a separate evidence attachment.

Subsection

Row

Field Label

Guidance

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.

If you select
“USPSTF Grade D,
Moderate or high
certainty that the
service has no net
benefit or harm
outweighs benefit”
in Row 111, then
Row 112 becomes a
becomes a required
field; otherwise, skip
to Row 113.

n/a

Evidence

112

*Is the selected

guideline statement
used to support an
inappropriate
use/care measure?

Evidence

113

114

*List all categories

and corresponding
definitions for the
evidence grading
system used to
describe level of
evidence or level of
certainty in the
evidence.

*Briefly summarize

the peer-reviewed
systematic review(s)
that inform this
measure concept

Select one.

Select one. Indicate whether the
guideline statement mentioned in “List
the guideline statement that most
closely aligns with the measure
concept” is used to promote the
practice of not performing a specific
action, process or intervention to
support an inappropriate use or
inappropriate care measure.
Insert the complete list of grading
categories and their definitions.

☐ Yes
☐ No

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

Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

between at least one process,
structure, or intervention with the
outcome.

Evidence

115

If there is lengthy text, submit details
via an evidence attachment.
If more than one article was identified,
provide at least one of the following for
one key article:
• Citation
• URL
• DOI

☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available

original research

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.
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
☐ No

*Peer-reviewed

If “Yes,” please provide documentation
of the search strategy in an attachment
(e.g., years searched, keywords and
search terms used, databases used,
etc.).
If more than one article was identified,
provide at least one of the following for
one key article:
• Citation
• URL
• DOI

*Peer-reviewed

systematic review
citation

Evidence

116

117

*Peer-reviewed

original research
citation

Evidence

118

119

*Summarize the
empirical data

*Empirical data
citation

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.
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. Describe the source of the
empirical data (e.g., peer-reviewed
narrative literature review, published
and publicly available reports, internal
data analysis, etc.).
If there is lengthy text, include details in
a separate evidence attachment.
If more than one empirical data was
identified, provide at least one of the
following for one key empirical data:
• Citation
• URL

☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available

Free text field

☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

• DOI

Evidence

120

*Summarize the
grey literature

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.
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

Provide the complete list of citations
with accompanying DOI or URL in a
separate attachment.
Evidence

121

*Grey literature

citation

Evidence

122

*Does the evidence
discuss a
relationship
between at least
one process,
structure, or
intervention with
the outcome?

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.
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.

☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available

☐ Yes
☐ No

Change #56
Location: Page 46-51, Risk Adjustment and Stratification, Row 123-136
Reason for Change: Relocated Risk Adjustment and Stratification row. Added and removed
rows. Updated Guidance, selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Risk
Adjustment
and
Stratification

149

*Was risk

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.

☐ Yes
☐ No

Risk
Adjustment
and
Stratification

adjustment and/or
stratification
considered?

150

If you select “Yes” in
Row 149, then Row
150 becomes a
required field. If you
select “No” in Row
149 then skip to
162.

*Was a conceptual

model outlining the
pathway between
patient risk factors,
quality of care, and
the outcome of
interest
established?

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.

Risk
Adjustment
and
Stratification

151

*Were all key risk
factors identified in
the conceptual
model available for
testing?

Risk
Adjustment
and
Stratification

152

*Is the measure risk
adjusted?

Select “No” if neither risk adjustment
nor stratification was considered as
part of the measure development
process.

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.

☐ Yes
☐ No

Select “No” if a conceptual model was
not established or the conceptual
model was based solely on expert
opinion or empirical analysis.

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).
Indicate whether the final measure is
risk adjusted.

☐ Yes
☐ No (enter here:)

☐ Yes
☐ No

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

n/a

This is not a data entry field.

Risk
Adjustment
and
Stratification

153

If you select “Yes” in
Row 152, then Row
153-160 becomes a
required field. 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 162.
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/Qualit
y-Initiatives-Patient-AssessmentInstruments/MMS/Downloads/Blueprin
t.pdf).

☐ 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):

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).

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Select “Patient community
characteristic” if the measure uses
information about the patient’s
community (e.g., percent of vacant
houses, crime rate).

Risk
Adjustment
and
Stratification

n/a

Risk
Adjustment
and
Stratification

154

Risk
Adjustment
and
Stratification

155

Risk
Adjustment
and
Stratification

156

If you select
“Patient
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.

Select “Other” if the risk factor is
related to the healthcare provider,
health system, or other factor that is
not related to the patient.
n/a

*Patient-level

Select all that apply

*Patient-level

Select all that apply

*Patient functional
status: please select
all that apply

Select all that apply

demographics:
please select all that
apply

health status &
clinical conditions:
please select all that
apply

This is not a data entry field.

☐ Age
☐ Sex
☐ Gender
☐ Race/ethnicity
☐ Other (enter here):
☐ Case-Mix Adjustment
☐ Severity of Illness
☐ Comorbidities
☐ Health behaviors/health choices
☐ Other (enter here):
☐ Body Function
☐ Ability to perform activities of daily living
☐ Other (enter here):

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Risk
Adjustment
and
Stratification

157

*Patient-level social

Select all that apply

☐ Income
☐ Education
☐ Wealth
☐ Living Alone
☐ Social Support
☐ Other (enter 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):

Risk
Adjustment
and
Stratification

159

*Patient
community
characteristic:
please select all that
apply

Select all that apply

☐ Percent of Vacant Houses
☐ Crime Rate
☐ Urban/Rural
☐ Other (enter here):

Risk
Adjustment
and
Stratification

160

*Risk model
performance

ADD YOUR CONTENT HERE

Risk
Adjustment
and
Stratification
n/a

161

*Is the measure
recommended to be
stratified?

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.
Indicate whether the final measure is
recommended to be stratified.

n/a

Risk
Adjustment
and
Stratification

162

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 153 then Row
162 becomes a
required field.
Otherwise skip to
Row 163.

*Stratification
approach

ADD YOUR CONTENT HERE

Risk
Adjustment
and
Stratification

163

*Rationale for not
using risk
adjustment or
stratification

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.
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-QualityMeasurement.pdf) and the guidance on
defining stratification schemes

risk factors: please
select all that apply

☐ Yes
☐ No

☐ Addressed through exclusions (e.g., process
measures)
☐ Addressed through stratification of results
☐ Not conceptually or empirically indicated (enter
here):
☐ Other (enter here):

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

(https://mmshub.cms.gov/measurelifecycle/measurespecification/developspecification/stratification)

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Risk
Adjustment
and
Stratification

123

*Is the measure

Indicate whether the final measure is
risk adjusted.

☐ Yes

n/a

If you select “Yes” in
Row 123, then Row
124 becomes a
become required
field. If you select
“No” in Row 123,
then skip to Row
134.

Risk
Adjustment
and
Stratification

124

*Was a conceptual

risk adjusted?

☐ No

Note that if you select “Yes,” you are
encouraged to upload documentation
about the risk adjustment model as an
attachment.

model outlining the
pathway between
patient risk factors,
quality of care, and
the outcome of
interest
established?

n/a

If you select “Yes” in
Row 124, then Row
125 becomes a
required field. If you
select “No” in Row
124, then skip to
Row 126.

Risk
Adjustment
and
Stratification

125

*Were all key risk

Risk
Adjustment
and
Stratification

126

factors identified in
the conceptual
model available for
testing?
Risk adjustment
variable types

n/a

This is not a data entry field.

☐ Yes
☐ No

Select “No” if a conceptual model was
not established or the conceptual
model was based solely on expert
opinion or empirical analysis.
n/a

This is not a data entry field.

If some key risk factors were not
available for testing or inclusion in the
risk model approach, select “No” and
describe the anticipated impact on
measure scores (e.g., magnitude and
direction of bias).

☐ Yes
☐ No (enter here:)

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 Blueprint
content on the CMS MMS Hub
(https://mmshub.cms.gov/measure-

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

lifecycle/measure-specification/dataprotocol/risk-adjustment).
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).

Risk
Adjustment
and
Stratification

n/a

If you select
“Patient-Level
Demographics” in
Row 126, then Row
127 becomes a
required field. If you
select “Patient-level
health status &
clinical conditions”
in Row 126, then
Row 128 becomes a
required field. If you
select “Patient
functional status” in

Select “Other” if the risk factor is
related to the healthcare provider,
health system, or other factor that is
not related to the patient.
n/a

This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

*Patient-level

Select all that apply

*Patient-level

Select all that apply

Row 126, then Row
129 becomes a
required field. If you
select “Patient-level
social risk factors”
in Row 126, then
Row 130 becomes a
required field. If you
select “Proxy social
risk factors” in Row
126, then Row 131
becomes a required
field. If you select
“Patient community
characteristics” in
Row 126, then Row
132 becomes a
required field.

Risk
Adjustment
and
Stratification

127

Risk
Adjustment
and
Stratification

128

Risk
Adjustment
and
Stratification
Risk
Adjustment
and
Stratification

129

*Patient functional
status: please select
all that apply

Select all that apply

130

*Patient-level social

Select all that apply

Risk
Adjustment
and
Stratification
Risk
Adjustment
and
Stratification

131

*Proxy social risk

Select all that apply

*Patient

Select all that apply

☐ Percent of Vacant Houses
☐ Crime Rate
☐ Urban/Rural
☐ Other (enter here):

Risk
Adjustment
and
Stratification

133

*Risk model

Free text field

Risk
Adjustment
and
Stratification

134

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.
Select one. Indicate whether the final
measure is recommended to be
stratified. Indicate whether the

demographics:
please select all that
apply

health status &
clinical conditions:
please select all that
apply

risk factors: please
select all that apply

factors: please
select all that apply
132

community
characteristics:
please select all that
apply
performance

*Is the measure
recommended to
be stratified based
on evidence from

☐ Income
☐ Education
☐ Wealth
☐ Living Alone
☐ Social Support
☐ Other (enter here):
☐ Neighborhood Level Income from the Census
☐ Dual Eligibility for Medicare and Medicaid
☐ Other (enter here):

☐ Yes, the measure is recommended to be stratified to
address an equity gap
☐ Yes, the measure is recommended to be stratified
for reasons unrelated to an equity gap

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

testing and/or
literature?

recommended stratification is intended
to address an equity gap.

☐ Yes, the measure is recommended to be stratified
both to address an equity gap AND for other reasons ☐
No, the measure is not recommended to be stratified

Health equity elements for stratification
include sociodemographic data such as
race, ethnicity, tribal sovereignty,
language, geography, sex, sexual
orientation and gender identity (SOGI),
language, income, and disability status,
as well as social determinants of health
(SDOH) featured in the Healthy People
2030 SDOH Framework across five
domains: economic stability, education
access and quality, health care access
and quality, neighborhood and built
environment, and social and
community context.

n/a

Risk
Adjustment
and
Stratification

135

If you select a “Yes”
response in Row
134, then Row 135
becomes a required
field. If you select a
“No” response in
Row 134 AND
selected a “No”
response in Row
123, then Row 136
becomes a required
field. Otherwise skip
to Row 137.

*Stratification

approach

For more information about health
equity elements, please refer to the
Equity Data Standardization page on
the CMS MMS Hub and the CMS Office
of Minority Heath white paper titled
“The Path Forward: Improving Data to
Advance Health Equity Solutions,”
available at:
https://mmshub.cms.gov/aboutquality/quality-at-CMS/goals/cmsfocus-on-health-equity/equity-datastandardization.
n/a

Describe the recommended
stratification approach including the
data elements used to stratify scores
for subgroups. Demonstrate that there
is sufficient sample size within
measured entities to stratify measure
scores.

This is not a data entry field.

Free text field

Indicate whether the recommendation
to stratify the measure is based on
evidence from testing and/or the
literature.
If findings from testing informed the
recommendation to stratify the
measure, summarize the findings

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

indicating that stratification would
improve interpretation of measure
results. If more room is needed,
provide testing results as an
attachment and list the name of the
attachment in this field.

Risk
Adjustment
and
Stratification

136

*Rationale for using

neither risk
adjustment nor
stratification

If evidence from the literature informed
the recommendation to stratify the
measure, provide citations supporting
your stratification approach.
Select ALL reasons for not
implementing a risk adjustment model
or stratification approach in the
measure. For more information, refer
to the Risk Adjustment in Quality
Measurement supplemental material
on the CMS MMS Hub
(https://mmshub.cms.gov/tools-andresources/mms-supplementalmaterials) and the guidance on defining
stratification schemes
(https://mmshub.cms.gov/measurelifecycle/measurespecification/developspecification/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):
☐ Risk adjustment and stratification were not
considered during development or testing
☐ Other (enter here):

Change #57
Location: Page 52, Healthcare Domain, Row 137-138
Reason for Change: Relocated Healthcare Domain rows. Updated Field Label.
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/meaningfulmeasures-20-moving-measurereduction-modernization

☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health

Healthcare
Domain

165

What, if any,
additional
Meaningful
Measure 2.0
priorities apply to
this measure?

Select up to two additional Meaningful
Measures 2.0 priorities that apply to
this measure.

☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health

For more information, see:
https://www.cms.gov/meaningfulmeasures-20-moving-measurereduction-modernization

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Healthcare
Domain

137

*What one

Select the ONE most applicable
Meaningful Measures 2.0 priority. For
more information, see:
https://www.cms.gov/meaningfulmeasures-20-moving-measurereduction-modernization

Healthcare
Domain

138

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.

☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health
☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health

Meaningful
Measures 2.0
priority is most
applicable to this
measure?

For more information, see:
https://www.cms.gov/meaningfulmeasures-20-moving-measurereduction-modernization

Change #58
Location: Page 52, Other Priorities, Row 139
Reason for Change: Relocated Other Priorities. Updated Field Label.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Other
Priorities

166

*Does this measure

Select one.

☐ Yes
☐ No

address CMS
priorities to
improve maternal
health care and
maternal
outcomes?

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Other
Priorities

139

*Does this measure

Select one.

☐ Yes
☐ No

address CMS
priorities to
improve maternal
health care or
maternal
outcomes?

Change #59
Location: Page 53-54, Endorsement Characteristics, Row 140-146
Reason for Change: Relocated Endorsement Characteristics rows. Updated Guidance,
selection options, and skip logic.
CY 2023 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Endorsement
Characteristics

167

*What is the

Select only one. For information on
consensus-based entity (CMS
contractor) endorsement, measure ID,
and other information, refer to:
http://www.qualityforum.org/QPS/

Endorsement
Characteristics

168

*CBE ID (CMS
consensus-based
entity, or
endorsement ID)

Endorsement
Characteristics

169

n/a

Endorsement
Characteristics

170

If endorsed: Is the
measure being
submitted exactly
as endorsed by the
CMS CBE?
If you select “No” in
Row 169 then Rows
170-171 become
required fields.
If not exactly as
endorsed, specify
the locations of the
differences

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.
Select 'Yes' or 'No'. Note that 'Yes'
should only be selected if the
submission is an EXACT match to the
CBE-endorsed measure.

☐ Endorsed
☐ Endorsement removed
☐ Submitted
☐ Failed endorsement
☐ Never submitted
ADD YOUR CONTENT HERE

Endorsement
Characteristics

171

Endorsement
Characteristics

172

Endorsement
Characteristics

173

endorsement status
of the measure?

☐ Yes
☐ No

n/a

This is not a data entry field.

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):
ADD YOUR CONTENT HERE

If not exactly as
endorsed, describe
the nature of the
differences
If endorsed: Year of
most recent CDP
endorsement

Briefly describe the differences

Year of next
anticipated CDP
endorsement
review

Select one. If you are submitting for
initial endorsement, select the
anticipated year.

Select one

☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
☐ 2022
☐ 2023
☐ 2024
☐ 2025

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ 2026
☐ 2027

CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Endorsement
Characteristics

140

*What is the

Select only one. For information on
consensus-based entity (CBE)
endorsement, measure ID, and other
information, refer to:
https://p4qm.org/

☐ Endorsed
☐ Endorsed with conditions
☐ Endorsement removed
☐ Submitted
☐ Failed endorsement or decision to not endorse

endorsement status
of the measure?

☐ Never submitted

ADD YOUR CONTENT HERE

*CBE ID (CMS

142

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.

n/a

If you select “No” in
Row 142, then Rows
143-144 become
required fields.

n/a

This is not a data entry field.

Endorsement
Characteristics

143

If not exactly as
endorsed, specify the
locations of the
differences

Indicate which specification fields are
different. Select all that apply

Endorsement
Characteristics

144

Briefly describe the differences

Endorsement
Characteristics

145

If not exactly as
endorsed, describe
the nature of the
differences
If endorsed: Year of
most recent CBE
endorsement

Endorsement
Characteristics

141

Endorsement
Characteristics

consensus-based
entity, or
endorsement ID)

Select one

☐ Yes
☐ No

☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Endorsement
Characteristics

146

Year of next
anticipated CBE
endorsement review

Select one. If you are submitting for
initial endorsement, select the
anticipated year.

☐ 2024
☐ 2025
☐ 2026
☐ 2027
☐ 2028

Change #60
Location: Page 55, Related and Competing Measures, Row 147-151
Reason for Change: Renamed section to Similar Measures. Relocated section. Added rows.
Updated Guidance, selection options, and skip logic.
CY 2023 Final Rule text:

RELATED AND COMPETING MEASURES

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Similar InUse
Measures

178

*Is this measure
related and/or
competing with
measure(s) already
in a program?

☐ Yes
☐ No

n/a

Related and
Competing
Measures

179

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.

Select either Yes or No. Related
measures are measures that address
either the same topic or the
same population, Competing measure
address both the same topic and
population.
n/a

Identify the other measure(s) including
title and any other unique identifier.

ADD YOUR CONTENT HERE

Related and
Competing
Measures

180

*How will this

Describe benefits of this measure, in
comparison to measure(s) already in a
program.

ADD YOUR CONTENT HERE

Related and
Competing
Measures

181

*How will this

Describe key differences that set this
measure apart from others.

ADD YOUR CONTENT HERE

*Which measure(s)
already in a
program is your
measure similar to
and/or competing
with?
measure add value
to the CMS
program?

measure be
distinguished from
other similar and/or
competing
measures?

This is not a data entry field.

CY 2024 Final Rule text:

SIMILAR MEASURES

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Related and
Competing
Measures

147

*Is this measure
related to and/or
competing with
measure(s) already
in a program?

Select either Yes or No. Consider other
measures with related purposes.

☐ Yes
☐ No

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

n/a

This is not a data entry field.

Related and
Competing
Measures

148

If you select “Yes” in
Row 147, then Rows
148-150 become
required fields. If
you select “No” in
Row 147, then skip
to Row 151.

*Which measure(s)

Identify the other measure(s) including
title and any other unique identifier.

Free text field

Related and
Competing
Measures

149

Describe benefits of this measure, in
comparison to measure(s) already in a
program.

Free text field

Related and
Competing
Measures

150

*How will this
measure add value
to the CMS
program?

Describe key differences that set this
measure apart from others.

Free text field

Related and
Competing
Measures

151

*Universal

Select one. Indicate whether this
measure is a Universal Foundation
quality measure.

☐ Measure is a Universal Foundation quality measure
(populations must align)
☐ Measure is not a Universal Foundation quality
measure

already in a
program is your
measure related to
and/or competing
with?

*How will this
measure be
distinguished from
other related
and/or competing
measures?
Foundation
Measure

To be considered a Universal
Foundation quality measure, the
submitted measure’s population must
align with the population of the existing
Universal Foundation measure (i.e.,
adult and/or pediatric).
Please refer to the “Aligning Quality
Measures Across CMS – the Universal
Foundation” webpage for more
information about Universal
Foundation of quality measures
available at:
https://www.cms.gov/aligning-qualitymeasures-across-cms-universalfoundation

Change #61
Location: Page 56, Attachments, Row 152-153
Reason for Change: Relocated Attachments section.
CY 2023 Final Rule text:

ATTACHMENTS

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

N/A

182

Attachment(s)

You are encouraged to attach the
measure information form (MIF) if
available. This is a detailed description

ADD YOUR CONTENT HERE

of the measure used by the CMS
consensus-based entity (CBE) during
endorsement proceedings. If a MIF is
not available, comprehensive measure
methodology documents are
encouraged.
If you are submitting for MIPS (either
Quality or Cost), you are required to
download the MIPS Peer Reviewed
Journal Article Template and attach the
completed form to your submission
using the “Attachments” feature. See
https://www.cms.gov/Medicare/Qualit
y-Initiatives-Patient-AssessmentInstruments/QualityMeasures/PreRulemaking
If your measure is risk adjusted, you are
encouraged to attach documentation
that provides additional detail about
the measure risk adjustment model
such as variables included, associated
code system codes, and risk adjustment
model coefficients

N/A

183

MIPS Peer
Reviewed Journal
Article Template

If eCQM, you must attach MAT
Output/HQMF, Bonnie test cases for
this measure, with 100% logic coverage
(test cases should be appended),
attestation that value sets are
published in VSAC, and feasibility
scorecard.
Select Yes or No. For those submitting
measures to MIPS program, enter
“Yes.” Attach your completed Peer
Reviewed Journal Article Template.

☐ Yes
☐ No

CY 2024 Final Rule text:

ATTACHMENTS

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

N/A

152

Attachment(s)

You are encouraged to attach the
measure information form (MIF) if
available. This is a detailed description
of the measure used by the CMS
consensus-based entity (CBE) during
endorsement proceedings. If a MIF is
not available, comprehensive measure
methodology documents are
encouraged.

ADD YOUR CONTENT HERE

If you are submitting for MIPS (either
Quality or Cost), you are required to
download the MIPS Peer Reviewed
Journal Article Template and attach the
completed form to your submission
using the “Attachments” feature. See
https://www.cms.gov/Medicare/Qualit
y-Initiatives-Patient-Assessment-

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Instruments/QualityMeasures/PreRulemaking
If your measure is risk adjusted, you are
encouraged to attach documentation
that provides additional detail about
the measure risk adjustment model
such as variables included, associated
code system codes, and risk adjustment
model coefficients

N/A

153

MIPS Peer
Reviewed Journal
Article Template

☐ Yes
☐ No

Change #62
Location: Page 56, Submitter Comments, Row 154
Reason for Change: Relocated and renamed Submitter Comments section.
CY 2023 Final Rule text:

COMMENTS

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

N/A

184

Submitter
Comments

Any notes, qualifiers, external
references, or other information not
specified above.

ADD YOUR CONTENT HERE

CY 2024 Final Rule text:

SUBMITTER COMMENTS

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

N/A

154

Submitter
Comments

Any notes, qualifiers, external
references, or other information not
specified above.

Free text field

Change #63
Location: Page 57-58, Appendix
Reason for Change: Updated row numbers.
CY 2023 Final Rule text:

Appendix: Lengthy Lists of Choices
A. 084-086
(086)

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

Agency for Healthcare Research & Quality
Alliance of Dedicated Cancer Centers
Ambulatory Surgical Center (ASC) Quality Collaboration
American Academy of Allergy, Asthma & Immunology
(AAAAI)
American Academy of Dermatology
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngology – Head and Neck
Surgery (AAOHN)
American College of Cardiology
American College of Cardiology/American Heart Association
American College of Emergency Physicians
American College of Emergency Physicians (previous
steward Partners-Brigham & Women's)
American College of Obstetricians and Gynecologists (ACOG)
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Gastroenterological Association
American Health Care Association
American Medical Association
American Nurses Association
American Psychological Association
American Society for Gastrointestinal Endoscopy
American Society for Radiation Oncology
American Society of Addiction Medicine
American Society of Anesthesiologists
American Society of Clinical Oncology
American Society of Clinical Oncology
American Urogynecologic Society
American Urological Association (AUA)
Audiology Quality Consortium/American Speech-LanguageHearing Association (AQC/ASHA)
Bridges to Excellence
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Eugene Gastroenterology Consultants, PC Oregon
Endoscopy Center, LLC
Health Resources and Services Administration (HRSA) HIV/AIDS Bureau
Heart Rhythm Society (HRS)
Indian Health Service
Infectious Diseases Society of America (IDSA)
Intersocietal Accreditation Commission (IAC)
KCQA- Kidney Care Quality Alliance

Minnesota (MN) Community Measurement
National Committee for Quality Assurance
National Minority Quality Forum
Office of the National Coordinator for Health Information
Technology/Centers for Medicare & Medicaid Services
Oregon Urology Institute
Oregon Urology Institute in collaboration with Large Urology
Group Practice Association
Pharmacy Quality Alliance
Philip R. Lee Institute for Health Policy Studies
Primary (care) Practice Research Network (PPRNet)
RAND Corporation
Renal Physicians Association; joint copyright with American
Medical Association Seattle Cancer Care Alliance
Society of Gynecologic Oncology
Society of Interventional Radiology
The Academy of Nutrition and Dietetics
The Joint Commission
The Society for Vascular Surgery
The University of Texas MD Anderson Cancer Center
University of Minnesota Rural Health Research Center
University of North Carolina- Chapel Hill
Wisconsin Collaborative for Healthcare Quality (WCHQ)
Other (enter in Row 084 and/or Row 086)

A.097 Choices for Areas of specialty (097)
Addiction medicine
Allergy/immunology
Anesthesiology
Behavioral health
Cardiac electrophysiology
Cardiac surgery
Cardiovascular disease (cardiology)
Chiropractic medicine
Colorectal surgery (proctology)
Critical care medicine (intensivists)
Dermatology
Diagnostic radiology
Electrophysiology
Emergency medicine
Endocrinology
Family practice
Gastroenterology
General practice
General surgery
Geriatric medicine
Gynecological oncology
Hand surgery
Hematology/oncology
Hospice and palliative care
Infectious disease
Internal medicine
Interventional pain management
Interventional radiology
Maxillofacial surgery
Medical oncology
Nephrology
Neurology
Neuropsychiatry
Neurosurgery
Nuclear medicine
Nursing
Nursing homes
Obstetrics/gynecology
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)

CY 2024 Final Rule text:

Appendix: Lengthy Lists of Choices
A. 085 Choices for Measure Steward and Long-Term Measure Steward (if different)
Agency for Healthcare Research & Quality
Alliance of Dedicated Cancer Centers
Ambulatory Surgical Center (ASC) Quality Collaboration
American Academy of Allergy, Asthma & Immunology
(AAAAI)
American Academy of Dermatology
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngology – Head and Neck
Surgery (AAOHN)
American College of Cardiology
American College of Cardiology/American Heart
Association
American College of Emergency Physicians
American College of Emergency Physicians (previous
steward Partners-Brigham & Women's)
American College of Obstetricians and Gynecologists
(ACOG)
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Gastroenterological Association
American Health Care Association
American Medical Association
American Nurses Association
American Psychological Association
American Society for Gastrointestinal Endoscopy
American Society for Radiation Oncology
American Society of Addiction Medicine
American Society of Anesthesiologists
American Society of Clinical Oncology
American Society of Clinical Oncology
American Urogynecologic Society
American Urological Association (AUA)
Audiology Quality Consortium/American SpeechLanguage-Hearing Association (AQC/ASHA)
Bridges to Excellence
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Eugene Gastroenterology Consultants, PC Oregon
Endoscopy Center, LLC
Health Resources and Services Administration (HRSA) HIV/AIDS Bureau
Heart Rhythm Society (HRS)
Indian Health Service
Infectious Diseases Society of America (IDSA)
Intersocietal Accreditation Commission (IAC)
KCQA- Kidney Care Quality Alliance
Minnesota (MN) Community Measurement
National Committee for Quality Assurance

National Minority Quality Forum
Office of the National Coordinator for Health Information
Technology/Centers for Medicare & Medicaid Services
Oregon Urology Institute
Oregon Urology Institute in collaboration with Large
Urology Group Practice Association
Pharmacy Quality Alliance
Philip R. Lee Institute for Health Policy Studies
Primary (care) Practice Research Network (PPRNet)
RAND Corporation
Renal Physicians Association; joint copyright with
American Medical Association Seattle Cancer Care Alliance
Society of Gynecologic Oncology
Society of Interventional Radiology
The Academy of Nutrition and Dietetics
The Joint Commission
The Society for Vascular Surgery
The University of Texas MD Anderson Cancer Center
University of Minnesota Rural Health Research Center
University of North Carolina- Chapel Hill
Wisconsin Collaborative for Healthcare Quality (WCHQ)
Other (enter in Row 084 and/or Row 086)

A.098 Choices for Areas of specialty
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)

100

File Type	application/pdf
File Title	MUC Data Template Crosswalk CY2023 Final Versus CY2024 Final
Subject	MUC, Data Template, Crosswalk, CY2023, CY2024, Final
Author	Centers for Medicare & Medicaid Services (CMS)
File Modified	2024-05-24
File Created	2024-05-21