ICD-10-CM Quality Payment Program Measures
Quality Measures are a set of tools under the Medicare program used to measure or quantify healthcare processes, outcomes, patient perceptions, and systems associated with the ability to provide high-quality health care.
ABCDEF Bundle - Early mobility for ICU patients
Description: Patients admitted to the intensive care unit (ICU) for > or = 4 days should be included in an early mobility program (E of ABCDEF Bundle) to improve their recovery process.
High Priority: YES
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Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period
Description: Percentage of patients aged 18 years and older who have undergone abdominal wall reconstruction defined as ventral hernia repair with myofascial release (abdominal wall fascial layer separated from muscular layer) who had a surgical site occurrence requiring procedural intervention within the 30 day postoperative period. Surgical site occurrences include any surgical site infections (superficial, deep, organ space) or any of the following: wound cellulitis, non-healing incisional wound, fascial disruption, skin or soft tissue ischemia, skin or soft tissue necrosis, wound serous drainage, wound purulent drainage, chronic sinus drainage, localized stab wound infection, stitch abscess, seroma, infected seroma, hematoma, infected hematoma, exposed biologic mesh, exposed synthetic mesh, contaminated biologic mesh, contaminated synthetic mesh, infected biologic mesh, infected synthetic mesh, mucocutaneous anastomosis disruption, enterocutaneous fistula). Procedural interventions include any of the following: wound opening, wound debridement, suture excision, percutaneous drainage, partial mesh removal, complete mesh removal. This measure is reported as three performance rates stratified by hernia width: 1) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Any hernia width (overall rate) 2) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of ≤10cm 3) Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period-Hernia width of >10cm
High Priority: YES
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Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year
Description: Proportion of patients receiving subcutaneous allergen immunotherapy that contains at least one standardized extract (mite, ragweed, grass, and/or cat) who achieved the projected effective dose for all included standardized allergen extract(s) after at least one year of treatment. National Quality Strategy Domain: Effective Clinical Care Outcome Measure
High Priority: YES
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Acquired Involutional Entropion: Normalized lid position after surgical repair
Description: Percentage of surgical entropion patients with normalized lid position within 90 days postoperatively.
High Priority: YES
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Activity counseling for back pain
Description: Percentage of patients 18 to 65 years of age who were counseled to remain active and exercise or were referred to physical therapy
High Priority: NO
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Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells
Description: Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells
High Priority: YES
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Acute Anterior Uveitis: Post-treatment visual acuity
Description: Percentage of acute anterior uveitis patients with a post-treatment best corrected visual acuity of 20/20 or better or patients whose visual acuity had returned to their baseline value prior to onset of uveitis.
High Priority: YES
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Acute Kidney Injury Requiring New Inpatient Dialysis
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive their first inpatient dialysis service for acute kidney injury during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
High Priority: NO
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Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Description: Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.
High Priority: YES
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Acute Treatment Prescribed for Cluster Headache
Description: Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed an acute treatment, including treatments prescribed by a different clinician.
High Priority: NO
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Additional improvements in access as a result of QIN/QIO TA
Description: As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services or improve care coordination (for example, investment of on-site diabetes educator).
High Priority: NO
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Adequate Compression at each visit for Patients with VLUs
Description: Percentage of venous leg ulcer visits among patients aged 18 years and older in which adequate compression is provided within the 12-month reporting period. Compression method should be appropriate to documented arterial supply. There are four rates reported for this measure. The four rates will be risk stratified into three buckets which are the following: 1. Normal arterial supply- No restrictions on type of compression 2. Compression bandaging with special considerations (e.g. short stretch bandaging, warnings to the patient to remove bandages if they feel too tight, etc.) 3. Compression bandaging not usually recommended 4. The average of the three risk stratified buckets which will be the performance rate in the XML submitted.
High Priority: NO
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Adequate Off-loading of Diabetic Foot Ulcer at each visit
Description: Percentage of visits in which diabetic foot ulcers among patients aged 18 years and received adequate off-loading during a 12-month reporting period, stratified by location of the ulcer. The location of the diabetic foot ulcer on the foot (e.g. heel/midfoot vs. toes) determines the type of off-loading device that is appropriate, the patient's risk of falling, the probability of successful off-loading and thus the likelihood of major amputation. The clinician needs to assess the most appropriate off-loading option based on many different factors. There are three rates reported for this measure. The three rates will be risk stratified into two buckets (location of wound and/or ulcer) which are the following: 1. Midfoot/heel 2. Toes 3. The average of the two risk stratified buckets which will be the performance rate in the XML submitted.
High Priority: NO
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Adherence to Antipsychotic Medications For Individuals with Schizophrenia
Description: Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.
High Priority: YES
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Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite
Description: Percentage of patients, aged 18 years and older, who undergo a cardiac operation using cardiopulmonary bypass for whom selected blood conservation strategies were used.
High Priority: NO
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Administration of the AHRQ Survey of Patient Safety Culture
Description: Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html).Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.
High Priority: NO
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Adult Diplopia: Improvement of ocular deviation or absence of diplopia or functional improvement
Description: Percentage of patients with a diagnosis of double vision (diplopia) who had an improvement of ocular deviation as determined by reduction of strabismus in primary gaze to <10 prism diopters horizontal or <2 prism diopters vertical deviation OR were absent of diplopia in primary gaze OR had functional improvement in ptosis within 6 months of initiating treatment.
High Priority: YES
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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Description: All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit.
High Priority: NO
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Adult OSA: Screening for Adult OSA by Primary Care Physicians
Description: All patients aged 18 years and older at high risk for obstructive sleep apnea (OSA) with documentation of screening for OSA using an appropriate standardized tool at least every 12 months AND in whom a recommended follow-up plan is documented based upon the result of the screening
High Priority: NO
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Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
Description: Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.
High Priority: YES
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Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
Description: Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.
High Priority: YES
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Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
Description: Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.
High Priority: YES
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Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Description: Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.
High Priority: YES
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Adult Surgical Esotropia: Postoperative alignment
Description: Percentage of adult esotropia patients receiving surgical treatment with a post treatment alignment of 12 prism diopters (PD) or less.
High Priority: YES
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Advance Care Plan
Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
High Priority: YES
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Advance Care Planning
Description: Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.
High Priority: NO
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Advance Directives Completed
Description: Percentage of patients aged 18 years and older with a diagnosis of Stage 3, 4 & 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) who have advance directives and/or end of life medical orders (e.g., POLST, MOLST, MOST, POST, etc.) completed based on their preferences.
High Priority: YES
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Age Appropriate Screening Colonoscopy
Description: The percentage of screening colonoscopies performed in patients greater than or equal to 86 years of age from January 1 to December 31.
High Priority: YES
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Age-related Hearing Loss: Audiometric Evaluation
Description: Percentage of patients age 60 years and older who failed a hearing screening and/or who report suspected hearing loss who received, were ordered, or were referred for comprehensive audiometric evaluation within 4 weeks the office visit.
High Priority: YES
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Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Description: Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period.
High Priority: NO
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Airway Assessment for patients undergoing Rhinoplasty
Description: Percentage of patients aged 15 years and older who had a rhinoplasty procedure for whom the nasal airway was assessed with physical examination via anterior rhinoscopy and/or speculum examination (lighted or not) and status of the septum, turbinates, and valves was documented.
High Priority: YES
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Alcohol Use Disorder Outcome Response
Description: The percentage of adult patients (18 years of age or older) who report problems with drinking alcohol AND with documentation of a standardized screening tool (e.g., AUDIT, AUDIT-C, DAST, TAPS) AND demonstrated a response to treatment at three months (+/- 60 days) after the index visit
High Priority: YES
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All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)
Description: Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service (FFS) beneficiaries 65 years and older with multiple chronic conditions (MCCs) who are assigned to the Accountable Care Organization (ACO)
High Priority: YES
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Allergic Rhinitis: Avoidance of Leukotriene Inhibitors
Description: Percentage of patients age 2 years and older patients with allergic rhinitis who do not receive leukotriene inhibitors
High Priority: YES
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Allergic Rhinitis: Intranasal Corticosteroids or Oral Antihistamines
Description: Percentage of patients age 2 years and older with allergic rhinitis who are offered intranasal corticosteroids (INS) or non-sedating oral antihistamines
High Priority: NO
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Amblyopia: Interocular visual acuity
Description: Percentage of newly diagnosed amblyopic patients with one or more of the following: A. a corrected interocular (or if not reported, the uncorrected) visual acuity difference < 0.23 logMAR 3-12 months after first diagnosis of amblyopia OR B. an improvement in the corrected visual acuity of the amblyopic eye of 3 or more Snellen lines (> or = 0.30 logMAR) 3-12 months after first diagnosis of amblyopia OR C. a final visual acuity in the amblyopic eye equal to 20/30 or better (less than or equal to 0.18 logMar) 3-12 months after first diagnosis of amblyopia
High Priority: YES
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Ambulatory Glucose Management
Description: Percentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period. The measure consists of four performance rates: a. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery whose blood glucose level is tested prior to the start of anesthesia b. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level >180 mg/dL (10.0 mmol/L) who received insulin prior to anesthesia end time c. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who received insulin perioperatively and who received a follow-up blood glucose level check following the administration of insulin and prior to discharge d. Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level >180 mg/dL (10.0 mmol/L) who received education on managing their glucose in the postoperative period prior to discharge
High Priority: NO
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Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
Description: Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually.
High Priority: YES
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Anastomotic Leak Intervention
Description: Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.
High Priority: YES
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Anesthesiology Smoking Abstinence
Description: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.
High Priority: YES
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Ankylosing Spondylitis: Appropriate Pharmacologic Therapy
Description: Percentage of patients aged 18 years and older with a first diagnosis of ankylosing spondylitis who are treated with nonsteroidal anti-inflammatory drugs (NSAIDs) before initiation of biologic therapy.
High Priority: YES
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Ankylosing Spondylitis: Controlled Disease
Description: Percentage of qualifying visits for patients aged 18 years and older with a diagnosis of ankylosing spondylitis for at least 6 months whose most recent BASDAI score is less than 4.
High Priority: YES
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Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Description: Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.
High Priority: NO
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Antibiotic Prophylaxis for High Risk Cardiac / Orthopedic Cases prior to Mohs micrographic surgery - Prevention of Overuse
Description: Percentage of cases of Mohs surgery in which preoperative prophylactic antibiotics were provided for which the patient had cardiac / orthopedic prophylaxis indications for preoperative antibiotics.
High Priority: YES
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Anticoagulant Management Improvements
Description: Individual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities:- Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program);- Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;- Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;- For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; or- For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.
High Priority: NO
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Anti-Depressant Medication Management
Description: Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
High Priority: NO
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Anxiety Response at 6-months
Description: The percentage of adult patients (18 years of age or older) with an anxiety disorder (generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment at 6-months (+/- 60 days) after an index visit.
High Priority: YES
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Appropriate Antiemetic Therapy for High- and Moderate Emetic Risk Antineoplastic Agents
Description: Percentage of cancer patients aged ≥18 years treated with high- or moderate-emetic risk antineoplastic agents who are administered appropriate pre-treatment antiemetic therapy The overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).
High Priority: NO
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Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
Description: Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.
High Priority: NO
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Appropriate diagnosis verification and severity grading for valve disease through transthoracic echocardiography (TTE) quantitative parameters.
Description: This measure addresses changes in cardiac structure and function in patients with aortic stenosis and/or mitral regurgitation. Changes in left ventricular size and function AND quantitative assessment of severity of aortic stenosis and/or mitral regurgitation should be performed in patients with significant left sided valvular lesions. Both sets of data (left ventricle structure and function, and extent of valvular disease) are needed to reach a conclusion about whether valve surgery or repair is needed. While qualitative assessments are commonly employed, they are generally inadequate to determine severity and to track changes over time. This is a multi-strata measure consisting of the following strata: 1. Percentage of transthoracic echocardiogram reports with at least moderate mitral regurgitation including qualitative MR severity, two quantitative MR measurements to support the qualitative severity grading, quantitative LVEF, one quantitative measurement of LV size at end diastole and end systole, AND blood pressure at time of study. 2. Percentage of transthoracic echocardiogram reports with at least moderate aortic stenosis including peak velocity, mean systolic gradient, aortic valve area, quantitative LVEF, one quantitative measurement of LV size at end diastole and end systole, AND blood pressure at the time of study The overall performance will be calculated using a weighted average.
High Priority: NO
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Appropriate Documentation of a Malnutrition Diagnosis
Description: Percentage of patients age 18 years and older who are found to be severely or moderately malnourished based on a nutrition assessment that have appropriate documentation in the medical record of a malnutrition diagnosis
High Priority: NO
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Appropriate Emergency Department Utilization of CT for Pulmonary Embolism
Description: Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level
High Priority: YES
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Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain
Description: Percentage of emergency department visits during which patients aged 18 years and older had a CT or MRI of the Lumbar Spine ordered by an emergency care provider, regardless of discharge disposition, presenting with acute, non-complex low back pain.
High Priority: YES
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Appropriate Evaluation of Left Ventricular Structure and Systolic Function with Transthoracic Echocardiography (TTE) to Guide Heart Failure and Cardiomyopathy Management
Description: This measure addresses appropriate evaluation of left ventricular structure and systolic function with TTE to guide heart failure and cardiomyopathy management on patients 18 years of age or older. It examines percentage (%) of comprehensive transthoracic echocardiogram (TTE) studies performed on patients with heart failure/cardiomyopathy as the reason for the study, and including the following parameters for the study: - LV end-diastolic and end systolic diameters, end diastolic LV interventricular septum thickness and LV posterior wall thickness measurements - LV mass index calculation - Strain technology utilization - Use of intravenous contrast agent to visualize endocardial borders for LV volumes and ejection fraction (EF) measurement in technically difficult studies.
High Priority: NO
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Appropriate Foley catheter use in the emergency department
Description: Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter
High Priority: YES
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Appropriate Follow-up Imaging for Incidental Abdominal Lesions
Description: Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow‐up imaging recommended based on radiological findings:• Cystic renal lesion that is simple appearing* (Bosniak I or II)• Adrenal lesion less than or equal to 1.0 cm• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign or diagnostic benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols
High Priority: YES
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Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
Description: Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.
High Priority: YES
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Appropriate follow-up interval based on pathology findings in screening colonoscopy
Description: Percentage of procedures among average-risk patients aged 50 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report
High Priority: YES
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Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Description: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
High Priority: YES
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Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS)
Description: The percentage of final reports for female patients receiving a transvaginal ultrasound (US) examination of the pelvis (including transabdominal/transvaginal exams) where a clinically relevant lesion is detected, in which the radiologist describes the lesion using O-RADS Lexicon Descriptors and subsequently makes the correct clinical management recommendation based on the O-RADS Risk Stratification and Management System.
High Priority: YES
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Appropriate management of anticoagulation in the peri-procedural period rate – EGD
Description: Percentage of patients undergoing an EGD on an anti-platelet agent or an anticoagulant who leave the endoscopy unit with instructions for management of this medication
High Priority: YES
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Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention
Description: Proportion of patients with non-invasive evaluations present/available prior to LE peripheral vascular interventions in patients with intermittent claudication.
High Priority: NO
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Appropriate Testing for Pharyngitis
Description: The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test.
High Priority: YES
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Appropriate Treatment for Adults with Upper Respiratory Infection (URI)
Description: Percentage of adults 18 years and older who were diagnosed with upper respiratory infection (URI) and were dispensed or administered an antibiotic prescription on or up to three days after the ED encounter
High Priority: YES
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Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer
Description: Percentage of female patients aged 18 to 70 with stage I (T1c) - III HER2 positive breast cancer for whom appropriate treatment is initiated.
High Priority: YES
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Appropriate Treatment for Upper Respiratory Infection (URI)
Description: Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event.
High Priority: YES
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Appropriate Treatment of Psychosis and Agitation in the Emergency Department
Description: Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department
High Priority: NO
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Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Description: Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.
High Priority: YES
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Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcers
Description: Percentage of patient with a diagnosis of a diabetic foot ulcer graded stage 3 or higher on the Wagner Grading System for Diabetic Foot Infections that received hyperbaric oxygen therapy (HBOT) appropriately.
High Priority: YES
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Appropriate Use of Imaging for Recurrent Renal Colic
Description: Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered.
High Priority: YES
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Appropriate Utilization of FAST Exam in the Emergency Department
Description: Percentage of emergency department visits for patients aged 18 years and older presenting with hemodynamically unstable blunt abdominal trauma (blunt trauma and a systolic blood pressure <90 mmHg or heart rate >120 bpm) or penetrating thoracoabdominal trauma who had a FAST exam ordered and/or performed during the emergency department visit
High Priority: YES
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Appropriate Workup Prior to Endometrial Ablation
Description: Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.
High Priority: YES
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Arteriovenous Fistulae Thrombectomy Success Rate
Description: Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients aged 18 years and older on maintenance hemodialysis dialysis
High Priority: YES
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Arteriovenous Graft Thrombectomy Success Rate
Description: Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients aged 18 years and older.
High Priority: YES
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Assessment for and management of immune-related adverse events during cancer treatment with checkpoint inhibitors (ICPi)
Description: Percentage of patients aged 18 and older receiving a checkpoint inhibitor (ICPi) for cancer experiencing immune-related adverse events of documented grade 3+ diarrhea OR documented grade 3+ hypothyroidism OR documented grade 3+ dermatitis OR documented grade 3+ pneumonitis AND for each adverse event, there is guideline concordant intervention (per ASCO/NCCN guideline) during the measurement period.
High Priority: YES
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Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist
Description: Percentage of patients age 18 years and older who are nutritionally at-risk that have documented nutrition intervention recommendations by a registered dietitian nutritionist or clinical qualified nutrition professional if identified with moderate or severe malnutrition as part of a nutrition assessment
High Priority: NO
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Asthma Control: Minimal Important Difference Improvement
Description: Percentage of patients aged 12 years and older whose asthma is not well-controlled as indicated by the Asthma Control Test, Asthma Control Questionnaire, or Asthma Therapy Assessment Questionnaire and who demonstrated a minimal important difference improvement upon a subsequent office visit during the 12-month reporting period. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Outcome Measure
High Priority: YES
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Asthma: Assessment of Asthma Control – Ambulatory Care Setting
Description: Percentage of patients aged 5 years and older with a diagnosis of asthma who were evaluated at least once during the measurement period for asthma control (comprising asthma impairment and asthma risk). National Quality Strategy Domain: Effective Clinical Care Process Measure
High Priority: NO
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Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Description: Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Avoid Head CT for Patients with Uncomplicated Syncope
Description: Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
Description: The percentage of episodes for patients ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass
Description: Percentage of patients, aged 18 years and older, undergoing a procedure using cardiopulmonary bypass who did not have a documented intraoperative pulmonary artery, oropharyngeal, or nasopharyngeal temperature ≥37.0 degrees Celsius during the period of cardiopulmonary bypass
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Co-Prescribing of Opioid Analgesic and Benzodiazepine
Description: Percentage of Patients Who Were Not Concurrently Prescribed Opioid Analgesic and Benzodiazepine Medications
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Echocardiogram and Carotid Ultrasound for Syncope
Description: Percentage of Patients Presenting with Syncope Who Did Not Have an Echocardiogram or Carotid Ultrasound Ordered
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain
Description: Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Opiates for Low Back Pain or Migraines
Description: Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Opioid Prescriptions for Closure and Reconstruction After Skin Cancer Resection
Description: Percentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, who had intermediate layer and/or complex linear closures OR reconstruction after skin cancer resection where opioid/narcotic therapy* was prescribed as first line therapy (as defined by a prescription in anticipation of or at time of surgery) for post-operative pain management by the reconstructing surgeon. (Inverse measure)
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Opioid therapy for migraine, low back pain, dental pain
Description: All ED encounters for patients aged 18 years and older with diagnosis of migraine or low back pain or dental pain who were prescribed or administered Opioids or Opiates
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures
Description: Percentage of procedures in patients aged 18 and older with a diagnosis of skin cancer who underwent intermediate layer or complex linear closure or reconstruction after skin cancer resection in the office-based* setting who were prescribed post-operative systemic antibiotics to be taken immediately following reconstruction surgery (inverse measure) This measure is stratified by intermediate layer or complex linear closure or reconstructive procedures.
High Priority: YES
Linked ICD-10 Codes:
Avoidance of Routine Antibiotic Use in Patients Before or After Intravitreal Injections
Description: The percentage of patients, aged 18 years and older, who received topical or systemic antibiotics before or after intravitreal injections
High Priority: YES
Linked ICD-10 Codes:
Back Pain After Lumbar Discectomy/Laminectomy
Description: For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.
High Priority: YES
Linked ICD-10 Codes:
Back Pain After Lumbar Fusion
Description: For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively.* hereafter referred to as VAS Pain
High Priority: YES
Linked ICD-10 Codes:
Barrett’s Esophagus
Description: Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia.
High Priority: NO
Linked ICD-10 Codes:
Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan (Inverse Measure)
Description: Percentage of patients age 16 years and older with a new onset diagnosis of Bell’s palsy within the past 3 months who had a magnetic resonance imaging (MRI) or a computed tomography scan (CT) of the internal auditory canal, head, neck or brain ordered for the primary diagnosis of Bell’s palsy.
High Priority: YES
Linked ICD-10 Codes:
Benign Positional Paroxysmal Vertigo (BPPV): Dix-Hallpike and Canalith Repositioning
Description: Percentage of patients with BPPV who had a Dix-Hallpike maneuver performed AND who had therapeutic canalith repositioning procedure (CRP) performed or who were referred for physical therapy or to a provider who can perform CRP if identified with posterior canal BPPV
High Priority: NO
Linked ICD-10 Codes:
Benign Prostate Hyperplasia (BPH): Inappropriate Lab & Imaging Services for Patients with BPH
Description: Percentage of patients with new diagnosis of BPH who had a creatinine lab order placed or had a CT abdomen, MRI abdomen, ultrasound abdomen ordered or performed.
High Priority: YES
Linked ICD-10 Codes:
Biomarker Status to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer
Description: Percentage of non-small cell lung cancer (NSCLC) surgical pathology reports that include anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR), AND tyrosine protein kinase ROS1 mutation status.
High Priority: YES
Linked ICD-10 Codes:
Biopsy Follow-Up
Description: Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient.
High Priority: YES
Linked ICD-10 Codes:
Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
Description: Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.
High Priority: NO
Linked ICD-10 Codes:
Breast Cancer Screening
Description: Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Breast Reconstruction: Return to OR
Description: Percentage of female patients aged 18 years and older who had breast reconstruction who have an unplanned second operation on the reconstruction site within 60 days of the primary breast reconstruction procedure.
High Priority: YES
Linked ICD-10 Codes:
Bunion Outcome - Adult and Adolescent
Description: Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPs Clinician/Group Survey
Description: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The NQF endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: • Getting Timely Care, Appointments, and Information; (Not endorsed by NQF)• How well Providers Communicate; (Not endorsed by NQF)• Patient’s Rating of Provider; (NQF endorsed # 0005)• Access to Specialists; (Not endorsed by NQF)• Health Promotion and Education; (Not endorsed by NQF)• Shared Decision-Making; (Not endorsed by NQF) • Health Status and Functional Status; (Not endorsed by NQF)• Courteous and Helpful Office Staff; (NQF endorsed # 0005)• Care Coordination; (Not endorsed by NQF)• Stewardship of Patient Resources. (Not endorsed by NQF)
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Access to Specialists
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Care Coordination
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Courteous and Helpful Office Staff
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Health Promotion and Education
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Health Status and Functional Status
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: How Well Providers Communicate
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Patient’s Rating of Provider
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Shared Decision Making
Description:
High Priority: YES
Linked ICD-10 Codes:
CAHPS for MIPS SSM: Stewardship of Patient Resources
Description:
High Priority: YES
Linked ICD-10 Codes:
Cancer Protocol and Turnaround Time for Gastrointestinal Carcinomas: Gastric, Esophageal, Colorectal and Hepatocellular Carcinomas
Description: Percentage of all eligible pathology reports for gastric, esophageal, colorectal, and hepatocellular carcinoma specimens for which all required data elements of the gastrointestinal Cancer Protocols are recorded AND meet the maximum 4 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 4 business days). INSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score: 1. Percent of cases for which required data elements for all cancer protocols are recorded. 2. Percent of cases that meet the maximum 4 business day turnaround time. The overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%)
High Priority: YES
Linked ICD-10 Codes:
Cancer Protocol and Turnaround Time for Gynecologic and Genitourinary Carcinomas: Carcinoma of the Endometrium, Prostate, and Renal Tubular Origin
Description: Percentage of all eligible pathology reports for specimens of carcinoma of the endometrium, prostate and renal tubular origin in which the required data elements of the gynecologic and genitourinary Cancer Protocols are recorded AND meet the maximum 4 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 4 business days). INSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score: 1. Percent of cases for which specified data elements for all cancer protocols are recorded. 2. Percent of cases that meet the maximum 4 business day turnaround time. The overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%)
High Priority: YES
Linked ICD-10 Codes:
Cardiac Rehabilitation Patient Referral from an Outpatient Setting
Description: Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.
High Priority: YES
Linked ICD-10 Codes:
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
Description: Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period.
High Priority: YES
Linked ICD-10 Codes:
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
Description: Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status.
High Priority: YES
Linked ICD-10 Codes:
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
Description: Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.
High Priority: YES
Linked ICD-10 Codes:
Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
Description: Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:• Submission Age Criteria 1: Females 18-64 years of age• Submission Age Criteria 2: Males 18-64 years of age• Submission Age Criteria 3: Females 65 years of age and older• Submission Age Criteria 4: Males 65 years of age and older
High Priority: YES
Linked ICD-10 Codes:
Care coordination agreements that promote improvements in patient tracking across settings
Description: Establish effective care coordination and active referral management that could include one or more of the following:Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/orSystematically integrate information from referrals into the plan of care.
High Priority: NO
Linked ICD-10 Codes:
Care transition documentation practice improvements
Description: In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient's preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.
High Priority: NO
Linked ICD-10 Codes:
Care transition standard operational improvements
Description: Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/orPartner with community or hospital-based transitional care services.
High Priority: NO
Linked ICD-10 Codes:
Cataract Surgery: Difference Between Planned and Final Refraction
Description: Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.
High Priority: YES
Linked ICD-10 Codes:
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Description: Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.
High Priority: YES
Linked ICD-10 Codes:
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
Description: Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.
High Priority: YES
Linked ICD-10 Codes:
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
Description: Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.
High Priority: YES
Linked ICD-10 Codes:
CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain
Description: Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course Applying CDC's Guideline for Prescribing Opioids that reviews the 2016 Guideline for Prescribing Opioids for Chronic Pain. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.
High Priority: NO
Linked ICD-10 Codes:
Central Line Ultrasound Guidance
Description: Percentage of patients, regardless of age, in whom ultrasound guidance is used by the anesthesia clinician when placing a central line for those central lines that are placed in the internal jugular location.
High Priority: YES
Linked ICD-10 Codes:
Cervical Cancer Screening
Description: Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed within the last 3 years* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years
High Priority: NO
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED PAIN AND FUNCTIONAL STATUS FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION
Description: Measurement of the change in patient reported quality of life following spinal cord stimular implantation for failed back surgery syndrome. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, psychological well-being and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED QUALITY OF LIFE AND FUNCTIONAL STATUS FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATION
Description: Measurement of the change in patient reported quality of life following medial branch radiofrequency ablation. Quality of life measurement on standardized scale includes mobility, analgesic medication use, psychological well-being and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL CORTICOSTEROID INJECTION
Description: Measurement of the change in patient reported quality of life following caudal, lumbar, thoracic, or cervical epidural corticosteroid injection. Quality of life measurement on standardized scale includes pain, mobility, psychological well-being, analgesic medication use, and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL LYSIS OF ADHESIONS
Description: Measurement of the change in patient reported quality of life following epidural lysis of adhesions. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING INTERSPINOUS INDIRECT DECOMPRESSION (SPACER)
Description: Measurement of the change in patient reported quality of life following interspinous indirect decompression (spacer). Quality of life measurement on standardized scale includes pain, mobility, psychological well-being, analgesic medication use, and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING INTRATHECAL PUMP IMPLANTATION
Description: Measurement of the change in patient reported quality of life following intrathecal pump implantation. Quality of life measurement on standardized scale includes pain, mobility, psychological well-being, and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING MAJOR JOINT CORTICOSTEROID INJECTION
Description: Measurement of the change in patient reported quality of life following major joint corticosteroid injection. Quality of life measurement on standardized scale includes pain, mobility, analgesic medication use, and activities of daily living.
High Priority: YES
Linked ICD-10 Codes:
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Description: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
High Priority: YES
Linked ICD-10 Codes:
Childhood Immunization Status
Description: Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
High Priority: NO
Linked ICD-10 Codes:
Children Who Have Dental Decay or Cavities
Description: Percentage of children, 6 months - 20 years of age, who have had tooth decay or cavities during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Chlamydia Screening for Women
Description: Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Chronic Anterior Uveitis - Post-treatment visual acuity
Description: Percentage of chronic anterior uveitis patients with a post-treatment best corrected visual acuity of 20/30 or better or patients whose visual acuity had returned to their baseline value prior to onset of uveitis.
High Priority: YES
Linked ICD-10 Codes:
Chronic Care and Preventative Care Management for Empaneled Patients
Description: In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:- Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;- Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP)93 and the NCQA Heart/Stroke Recognition Program (HSRP)94;- Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;- Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;- Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/orUse reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.
High Priority: NO
Linked ICD-10 Codes:
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy
Description: Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator.
High Priority: NO
Linked ICD-10 Codes:
Chronic Skin Conditions: Patient Reported Quality-of-Life
Description: The percentage of patients aged 18 years and older with a chronic skin condition whose self-assessed quality-of-life was recorded at least once in the medical record within the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Clinical Data Registry Reporting
Description: The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.
High Priority: NO
Linked ICD-10 Codes:
Clinical Data Registry Reporting Exclusion
Description: Any MIPS eligible clinician who does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Clinical Data Registry Reporting for Multiple Registry Engagement
Description: Report as true if, active engagement with more than one Clinical Data Registry in accordance with PI_PHCDRR_5.
High Priority: NO
Linked ICD-10 Codes:
Clinical Outcome Post Endovascular Stroke Treatment
Description: Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention.
High Priority: YES
Linked ICD-10 Codes:
Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor Vehicles
Description: Percentage of Patients At Risk for Recurrent Loss of Consciousness For Whom Loss of Consciousness Information Was Submitted to Department of Public Health or Department of Motor Vehicles
High Priority: YES
Linked ICD-10 Codes:
Closing the Mohs Surgery Referral Loop: Transmission of Surgical Report
Description: Percentage of Mohs micrographic surgery cases or Mohs surgical defect reconstruction cases for which the reconstruction was performed by a different surgeon than the Mohs surgeon, regardless of patient age, for which a report is sent from the treating provider to the referring provider within 30 days.
High Priority: YES
Linked ICD-10 Codes:
Closing the Referral Loop: Receipt of Specialist Report
Description: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
High Priority: YES
Linked ICD-10 Codes:
Clostridium Difficile – Risk Assessment and Plan of Care
Description: Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission
High Priority: YES
Linked ICD-10 Codes:
Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding
Description: Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider
High Priority: YES
Linked ICD-10 Codes:
Cognitive Assessment with Counseling on Safety and Potential Risk
Description: Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) reporting of results included counseling on safety and potential risks.
High Priority: NO
Linked ICD-10 Codes:
Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
Description: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
High Priority: NO
Linked ICD-10 Codes:
Collection and use of patient experience and satisfaction data on access
Description: Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.
High Priority: NO
Linked ICD-10 Codes:
Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
Description: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.
High Priority: YES
Linked ICD-10 Codes:
Colorectal Cancer Screening
Description: Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.
High Priority: NO
Linked ICD-10 Codes:
Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event
Description: A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient's primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.
High Priority: NO
Linked ICD-10 Codes:
Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older
Description: Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.
High Priority: YES
Linked ICD-10 Codes:
Completion of an Accredited Safety or Quality Improvement Program
Description: Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:- The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;- The activity must have specific, measurable aim(s) for improvement;- The activity must include interventions intended to result in improvement;- The activity must include data collection and analysis of performance data to assess the impact of the interventions; and- The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).
High Priority: NO
Linked ICD-10 Codes:
Completion of CDC Training on Antibiotic Stewardship
Description: Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.
High Priority: NO
Linked ICD-10 Codes:
Completion of Collaborative Care Management Training Program
Description: To receive credit for this activity, MIPS eligible clinicians must complete a collaborative care management training program, such as the American Psychiatric Association (APA) Collaborative Care Model training program available to the public, in order to implement a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice.
High Priority: NO
Linked ICD-10 Codes:
Completion of the AMA STEPS Forward program
Description: Completion of the American Medical Association’s STEPS Forward program.
High Priority: NO
Linked ICD-10 Codes:
Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
Description: Completion of training and obtaining an approved waiver for provision of medication -assisted treatment of opioid use disorders using buprenorphine.
High Priority: NO
Linked ICD-10 Codes:
Complications After Cataract Surgery
Description: Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had the following complications with 90 days after cataract surgery: prolonged inflammation, incision complications, iris complications, retinal detachment, cystoid macular edema, corneal complications, or a return to OR.
High Priority: YES
Linked ICD-10 Codes:
Comprehensive Epilepsy Care Center Referral or Discussion for Patients with Epilepsy
Description: Percentage of patients who were referred or had a discussion of evaluation at a comprehensive epilepsy care center*.
High Priority: NO
Linked ICD-10 Codes:
Comprehensive Eye Exams
Description: To receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by any one or more of the following: - providing literature, - facilitating a conversation about this topic using resources such as the "Think About Your Eyes" campaign, - referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology's EyeCare America and the American Optometric Association's VISION USA, or - promoting access to vision rehabilitation services as appropriate for individuals with chronic vision impairment.This activity is intended for:- Non-ophthalmologists / optometrists who refer patients to an ophthalmologist/optometrist;- Ophthalmologists/optometrists caring for underserved patients at no cost; or- Any clinician providing literature and/or resources on this topic.This activity must be targeted at underserved and/or high-risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams or vision rehabilitation services.
High Priority: NO
Linked ICD-10 Codes:
Comprehensive TTE studies reporting a measured value of LVEF AND wall motion findings with LVEF < 50%
Description: Percentage of comprehensive TTE studies reporting a measured value of LVEF and wall motion findings with LVEF < 50% on patients 18 years of age or older.
High Priority: YES
Linked ICD-10 Codes:
Concurrent Chemo radiation for Patients with a Diagnosis of Stage IIIB NSCLC
Description: Percentage of patients, regardless of age, with a diagnosis of Stage IIIB non-small cell lung cancer (NSCLC) receiving concurrent chemoradiation.
High Priority: NO
Linked ICD-10 Codes:
Consultation for Frail Patients
Description: Percentage of patients aged 70 years or older, who undergo an inpatient procedure requiring anesthesia services and have a positive frailty screening result who receive a multidisciplinary consult or care during the hospital encounter
High Priority: YES
Linked ICD-10 Codes:
Consultation of the Prescription Drug Monitoring Program
Description: Clinicians would attest to reviewing the patients’ history of controlled substance prescription using state prescription drug monitoring program (PDMP) data prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription lasting longer than 3 days. For the transition year, clinicians would attest to 60 percent review of applicable patient’s history. For the Quality Payment Program Year 2 and future years, clinicians would attest to 75 percent review of applicable patient’s history performance.
High Priority: NO
Linked ICD-10 Codes:
Consulting AUC Using Clinical Decision Support when Ordering Advanced
Description: Clinicians attest that they are consulting specified applicable AUC through a qualified clinical decision support mechanism for all applicable imaging services furnished in an applicable setting, paid for under an applicable payment system, and ordered on or after January 1, 2018. This activity is for clinicians that are early adopters of the Medicare AUC program (2018 performance year) and for clinicians that begin the Medicare AUC program in future years as specified in our regulation at §414.94. The AUC program is required under section 218 of the Protecting Access to Medicare Act of 2014. Qualified mechanisms will be able to provide a report to the ordering clinician that can be used to assess patterns of image-ordering and improve upon those patterns to ensure that patients are receiving the most appropriate imaging for their individual condition.
High Priority: NO
Linked ICD-10 Codes:
Continuation of Anticoagulation Therapy in the Office-based Setting for Closure and Reconstruction After Skin Cancer Resection Procedures
Description: Percentage of procedures in patients, aged 18 and older with a diagnosis of skin cancer, on prescribed anticoagulation therapy, who had intermediate layer and/or complex linear closures OR reconstruction after skin cancer resection performed in the office-based setting where anticoagulant therapy was continued prior to surgery. This measure is stratified by intermediate layer or complex linear closures AND reconstructive procedures.
High Priority: YES
Linked ICD-10 Codes:
Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
Description: Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.
High Priority: YES
Linked ICD-10 Codes:
Controlling High Blood Pressure
Description: Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Coordination of Care for Anticoagulated Patients Undergoing Reconstruction After Skin Cancer Resection
Description: Percentage of patients aged 18 and older on prescribed anticoagulation medication who underwent reconstruction after skin cancer resection (in any setting) and preoperative modification* to their anticoagulant(s) regimen, who had documentation of coordinated care** prior to their procedure.
High Priority: YES
Linked ICD-10 Codes:
COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation
Description: Patients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapnic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available; and patients admitted with AHA Class D heart failure and/or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available
High Priority: YES
Linked ICD-10 Codes:
COPD: Steroids for no more than 5 days in COPD Exacerbation
Description: Patients should receive no more than 5 days of steroids in treatment for COPD Exacerbation from all sources and routes. Sources may include outpatient, Emergency Department, and Inpatient/Observation treatment. i.e. Full course of steroids not to exceed 7 days.
High Priority: YES
Linked ICD-10 Codes:
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
Description: Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.
High Priority: YES
Linked ICD-10 Codes:
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
Description: Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.
High Priority: NO
Linked ICD-10 Codes:
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Description: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.
High Priority: YES
Linked ICD-10 Codes:
Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure
Description: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours
High Priority: YES
Linked ICD-10 Codes:
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Description: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.
High Priority: YES
Linked ICD-10 Codes:
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy.
High Priority: NO
Linked ICD-10 Codes:
Coronary Artery Disease (CAD): Antiplatelet Therapy
Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.
High Priority: NO
Linked ICD-10 Codes:
Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)
Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy.
High Priority: NO
Linked ICD-10 Codes:
Cost Display for Laboratory and Radiographic Orders
Description: Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.
High Priority: NO
Linked ICD-10 Codes:
COVID-19 Clinical Data Reporting with or without Clinical Trial
Description: To receive credit for this improvement activity, a MIPS eligible clinician or group must: (1) participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study; or (2) participate in the care of patients diagnosed with COVID-19 and simultaneously submit relevant clinical data to a clinical data registry for ongoing or future COVID-19 research. Data would be submitted to the extent permitted by applicable privacy and security laws. Examples of COVID-19 clinical trials may be found on the U.S. National Library of Medicine website at https://clinicaltrials.gov/ct2/results?cond=COVID-19. In addition, examples of COVID-19 clinical data registries may be found on the National Institute of Health website at https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=COVID19+registries&commit=Search.
High Priority: NO
Linked ICD-10 Codes:
Critical Care Transfer of Care – Use of Verbal Checklist or Protocol
Description: Percentage of Adult Patients Transferred from the Critical Care Service to a Non-critical Care Service Who Had Documented Use of a Verbal Protocol for the Transfer of Care Between the Transferring Clinician and the Accepting Clinician
High Priority: YES
Linked ICD-10 Codes:
Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
Description: Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months.
High Priority: NO
Linked ICD-10 Codes:
Dementia: Cognitive Assessment
Description: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
High Priority: NO
Linked ICD-10 Codes:
Dementia: Education and Support of Caregivers for Patients with Dementia
Description: Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.
High Priority: YES
Linked ICD-10 Codes:
Dementia: Functional Status Assessment
Description: Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.
High Priority: NO
Linked ICD-10 Codes:
Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
Description: Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.
High Priority: YES
Linked ICD-10 Codes:
Depression Remission at Twelve Months
Description: The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.
High Priority: YES
Linked ICD-10 Codes:
Depression screening
Description: Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.
High Priority: NO
Linked ICD-10 Codes:
Dermatitis – Improvement in Patient-Reported Itch Severity
Description: The percentage of patients, aged 18 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient reported itch severity assessments performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.
High Priority: YES
Linked ICD-10 Codes:
DEXA/DXA and Fracture Risk Assessment for Patients with Osteopenia
Description: All patients, aged 40-90 at time of service, who undergo DEXA scans for bone density who have their FRAX score included in the final report.
High Priority: NO
Linked ICD-10 Codes:
Diabetes Care All or None Outcome Measure: Optimal Control
Description: The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: All or None Outcome Measure (Optimal Control) composite of A1C <8.0%, BP <130/80, Tobacco Non-User, Statin Use, and Daily Aspirin or Other Antiplatelet for diabetes patients with IVD.
High Priority: YES
Linked ICD-10 Codes:
Diabetes Care All or None Process Measure: Optimal Testing
Description: The percentage of diabetes patients 18 through 75 years of age who had the following during the 12-month measurement period: All or None Process Measure (Optimal Testing) composite of two A1C’s, one Kidney Function Monitoring Test and one eGFR Test
High Priority: NO
Linked ICD-10 Codes:
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
Description: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.
High Priority: NO
Linked ICD-10 Codes:
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
Description: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.
High Priority: NO
Linked ICD-10 Codes:
Diabetes screening
Description: Diabetes screening for people with schizophrenia or bipolar disease who are using antipsychotic medication.
High Priority: NO
Linked ICD-10 Codes:
Diabetes/Pre-Diabetes Screening for Patients with DSP
Description: Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for diabetes (e.g. fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered when seen for an initial evaluation for distal symmetric polyneuropathy and if screen positive referred to endocrinology or PCP.
High Priority: NO
Linked ICD-10 Codes:
Diabetes: Eye Exam
Description: Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Description: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Diabetes: Medical Attention for Nephropathy
Description: The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Diabetic Foot Ulcer (DFU) Healing or Closure
Description: Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required. There are four rates reported for this measure. Three of the rates will be risk stratified into three buckets (minimum-maximum) which are the following: 1. 0.00 – 62.42 2. 62.42 – 73.19 3. 73.19 – 93.45 4. The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted.
High Priority: YES
Linked ICD-10 Codes:
Diabetic Macular Edema - Loss of Visual Acuity
Description: Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) within the past 12 months.
High Priority: YES
Linked ICD-10 Codes:
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Description: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
High Priority: YES
Linked ICD-10 Codes:
Discharge Prescription of Naloxone after Opioid Poisoning or Overdose
Description: Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge
High Priority: YES
Linked ICD-10 Codes:
Disease Activity Measurement for Patients with PsA
Description: If a patient has psoriatic arthritis, then disease activity using a standardized measurement tool should be assessed at >=50% of encounters for PsA.
High Priority: NO
Linked ICD-10 Codes:
Documentation of Clinical Response to Allergen Immunotherapy within One Year
Description: Percentage of patients aged 5 years and older who were evaluated for clinical improvement and efficacy within one year after initiating allergen immunotherapy AND assessment documented in the medical record. National Quality Strategy Domain: Communication and Care Coordination Process Measure
High Priority: YES
Linked ICD-10 Codes:
Documentation of Current Medications in the Medical Record
Description: Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
High Priority: YES
Linked ICD-10 Codes:
Documentation of High-Risk Squamous Cell Carcinoma Stage in Mohs Micrographic Surgery Record
Description: Percentage of Mohs surgery cases for high risk cutaneous squamous cell carcinoma (SCC) of the head and neck for which America Joint Committee on Cancer (AJCC) 8th edition staging1, that was documented in the medical record. For these purposes high-risk is defined as a tumor stage greater than T2.
High Priority: YES
Linked ICD-10 Codes:
Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients
Description: Percentage of Urgent Care Patients Who Made Provider Contact Within 30 Minutes of Urgent Care Clinic (UCC) Arrival
High Priority: YES
Linked ICD-10 Codes:
Door to Puncture Time for Endovascular Stroke Treatment
Description: Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours.
High Priority: YES
Linked ICD-10 Codes:
Drug Cost Transparency
Description: To receive credit for this improvement activity, MIPS eligible clinicians must attest that their practice provides counseling to patients and/or their caregivers about the costs of drugs and the patients' out-of-pocket costs for the drugs. If appropriate, the clinician must also explore with their patients the availability of alternative drugs and patients' eligibility for patient assistance programs that provide free medications to people who cannot afford to buy their medicine. One source of information for pricing of pharmaceuticals could be a real-time benefit tool (RTBT), which provides to the prescriber, real-time patient-specific formulary and benefit information for drugs, including cost-sharing for a beneficiary. (CMS finalized in the Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out of Pocket Expenses final rule (84 FR 23832, 23883) that beginning January 1, 2021 Medicare Part D plans will be required to implement one or more RTBT(s).)
High Priority: NO
Linked ICD-10 Codes:
Dysphonia: Postoperative Laryngeal Examination
Description: Percentage of patients age 18 years and older who were diagnosed with new onset dysphonia within 2 months after a thyroidectomy who received or were referred for a laryngeal examination to examine vocal fold/cord mobility, and, if abnormal vocal fold mobility is identified, receive a plan of care for voice rehabilitation.
High Priority: NO
Linked ICD-10 Codes:
ED Median Time from ED arrival to ED departure for all Adult Patients
Description: Time (in minutes) from ED arrival to ED departure for all Adult Patients
High Priority: YES
Linked ICD-10 Codes:
ED Median Time from ED arrival to ED departure for all Pediatric Patients
Description: Time (in minutes) from ED arrival to ED departure for all Pediatric Patients
High Priority: YES
Linked ICD-10 Codes:
Elder Maltreatment Screen and Follow-Up Plan
Description: Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.
High Priority: YES
Linked ICD-10 Codes:
Elective Outpatient Percutaneous Coronary Intervention (PCI)
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from the PCI surgery that triggers the episode through 30 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Elective Primary Hip Arthroplasty
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive an elective primary hip arthroplasty during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Electronic Case Reporting
Description: The MIPS eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.
High Priority: NO
Linked ICD-10 Codes:
Electronic Case Reporting Exclusion
Description: Any MIPS eligible clinician who does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Electronic Case Reporting for Multiple Registry Engagement
Description: Report as true if, active engagement with more than one Electronic Case Reporting registry in accordance with PI_PHCDRR_3.
High Priority: NO
Linked ICD-10 Codes:
Electronic Health Record Enhancements for BH data capture
Description: Enhancements to an electronic health record to capture additional data on behavioral health (BH) populations and use that data for additional decision-making purposes (e.g., capture of additional BH data results in additional depression screening for at-risk patient not previously identified).
High Priority: NO
Linked ICD-10 Codes:
Electronic submission of Patient Centered Medical Home accreditation
Description: I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.
High Priority: NO
Linked ICD-10 Codes:
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Description: Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT
High Priority: YES
Linked ICD-10 Codes:
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Description: Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as high risk according to the PECARN prediction rules for traumatic brain injury
High Priority: YES
Linked ICD-10 Codes:
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Description: Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.
High Priority: YES
Linked ICD-10 Codes:
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Description: Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.
High Priority: YES
Linked ICD-10 Codes:
End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care
Description: End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care is the percentage of all adult ESRD patients on peritoneal dialysis (PD) or home hemodialysis.
High Priority: YES
Linked ICD-10 Codes:
Endothelial Keratoplasty – Dislocation Requiring Surgical Intervention
Description: Percentage of endothelial keratoplasty patients with a rebubbling or revision or repair procedure within 90 days after surgery
High Priority: YES
Linked ICD-10 Codes:
Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better
Description: Percentage of endothelial keratoplasty patients with a best corrected visual acuity of 20/40 or better within 90 days after surgery
High Priority: YES
Linked ICD-10 Codes:
Engage Patients and Families to Guide Improvement in the System of Care
Description: Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.
High Priority: NO
Linked ICD-10 Codes:
Engagement of community for health status improvement
Description: Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.
High Priority: NO
Linked ICD-10 Codes:
Engagement of New Medicaid Patients and Follow-up
Description: Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.
High Priority: NO
Linked ICD-10 Codes:
Engagement of patients through implementation of improvements in patient portal
Description: To receive credit for this activity, MIPS eligible clinicians must provide access to an enhanced patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; or any relevant acute or chronic disease management.
High Priority: NO
Linked ICD-10 Codes:
Engagement of Patients, Family, and Caregivers in Developing a Plan of Care
Description: Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.
High Priority: NO
Linked ICD-10 Codes:
Engagement with QIN-QIO to implement self-management training programs
Description: Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.
High Priority: NO
Linked ICD-10 Codes:
Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
Description: Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973
High Priority: NO
Linked ICD-10 Codes:
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
Description: Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.
High Priority: NO
Linked ICD-10 Codes:
e-Prescribing
Description: At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.
High Priority: NO
Linked ICD-10 Codes:
e-Prescribing Exclusion
Description: Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT
Description: Percentage of patients with a macular hole who have evidence of anatomic closure documented by OCT within 90 days after surgical treatment.
High Priority: YES
Linked ICD-10 Codes:
Evidenced-based techniques to promote self-management into usual care
Description: Incorporate evidence-based techniques to promote self-management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing.
High Priority: NO
Linked ICD-10 Codes:
Exercise and Appropriate Physical Activity Counseling for Patients with MS
Description: Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate physical activity for patients with MS in the past 12 months.
High Priority: NO
Linked ICD-10 Codes:
Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy
Description: Percentage of patients aged 45 and higher undergoing primary arthroscopic partial meniscectomy (APM) surgery who do not have grade IV chondromalacia in more than one compartment. On a per-surgeon level, the measure is expected to be 70% or higher; on a system level, the measure is expected to be 80% or higher.
High Priority: NO
Linked ICD-10 Codes:
Exudative Age-Related Macular Degeneration: Loss of Visual Acuity
Description: Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) of visual acuity within the past 12 months. First performance rate used for reporting.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.
Description: The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.
Description: The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with knee injury pain.
Description: The proportion of patients failing to achieve MCID of two (2) points or more improvement in the NPRS change score for patients with knee injuries treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with low back pain.
Description: The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.
Description: The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.
Description: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.
Description: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported. Additionally, a risk-adjusted DASH change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).
Description: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported. Additionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.
Description: The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.
Description: The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.
High Priority: YES
Linked ICD-10 Codes:
Falls: Plan of Care
Description: Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.
High Priority: YES
Linked ICD-10 Codes:
Falls: Risk Assessment
Description: Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months.
High Priority: YES
Linked ICD-10 Codes:
Falls: Screening for Future Fall Risk
Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Fatigue Screening and Follow-Up for Patients with MS
Description: Percentage of patients with MS who were screened for fatigue in past 12 months, and if screening positive were provided appropriate follow-up.
High Priority: NO
Linked ICD-10 Codes:
Femoral or Inguinal Hernia Repair
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Femoral or Inguinal Hernia Repair episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgical procedure to repair a femoral or inguinal hernia during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Financial Navigation Program
Description: In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.
High Priority: NO
Linked ICD-10 Codes:
Folic or Folinic Acid Therapy for Patients Treated with Methotrexate
Description: Percentage of patients aged 18 years and older being treated with methotrexate who are concomitantly treated with folic or folinic acid.
High Priority: NO
Linked ICD-10 Codes:
Follow-Up After Hospitalization for Mental Illness (FUH)
Description: The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: • The percentage of discharges for which the patient received follow-up within 30 days after discharge. • The percentage of discharges for which the patient received follow-up within 7 days after discharge.
High Priority: YES
Linked ICD-10 Codes:
Follow-Up Care Coordination Documented in Discharge Summary
Description: Percentage of patients aged 18 years and older for which follow-up care coordination was documented in Hospital Discharge Summary
High Priority: YES
Linked ICD-10 Codes:
Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Description: Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a) Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.b) Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
High Priority: NO
Linked ICD-10 Codes:
Functional Benefit of a Cochlear Implant
Description: Percentage of patients aged 18 years and older, who are evaluated for hearing loss and complete a hearing loss self-assessment tool that indicated an impact of hearing-related quality of life (QoL), and if diagnosed with a bilateral moderate to profound sensorineural hearing loss (SNHL) and less than 60% open set speech recognition are scheduled or referred for cochlear implant candidacy testing AND for patients who undergo cochlear implantation, demonstrate a meaningful clinically important difference (MCID) improvement in self-assessment of Hearing-related QoL or an improvement in speech recognition within 18 months of cochlear implant activation.
High Priority: YES
Linked ICD-10 Codes:
Functional Outcome Assessment
Description: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
High Priority: YES
Linked ICD-10 Codes:
Functional Status After Lumbar Discectomy/Laminectomy
Description: For patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively.* hereafter referred to as ODI
High Priority: YES
Linked ICD-10 Codes:
Functional Status After Lumbar Fusion
Description: For patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a)* at one year (9 to 15 months) postoperatively.* hereafter referred to as ODI
High Priority: YES
Linked ICD-10 Codes:
Functional Status After Primary Total Knee Replacement
Description: For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Assessment for Total Hip Replacement
Description: Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Assessment for Total Knee Replacement
Description: Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Assessments for Congestive Heart Failure
Description: Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients Post Stroke: Lower Body
Description: This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ who have experienced a stroke with sequelae impacting functional abilities related to use of the foot, leg, and lower trunk. The change in FS is assessed using the Stroke Lower Extremity (SLE) FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient level, individual clinician level, and clinic level to assess quality. Free public access is available at https://www.fotoinc.com/science-of-foto/nqf-measure-specifications.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients Post Stroke: Upper Body
Description: This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ who have experienced a stroke with sequelae impacting functional abilities related to use of the hand, arm, and upper trunk. The change in FS is assessed using the Stroke Upper Extremity (SUE) FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient level, individual clinician level, and clinic level to assess quality. Free public access is available at https://www.fotoinc.com/science-of-foto/nqf-measure-specifications.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with elbow, wrist, or hand impairments. The change in functional status (FS) is assessed using the FOTO Elbow/Wrist/Hand FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Hip Impairments
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Knee Impairments
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients With Low Back Functional Status Deficit
Description: Percentage of patients aged 18 years or older with a functional deficit related to the low back who achieve a Minimal Clinically Important Difference (MCID) in the Modified Oswestry Low Back Pain Questionnaire (ODI) or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported: · The overall proportion of patients achieving an MCID in NDI change score. · The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via NDI or equivalent tool) proportion is greater than zero. The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Low Back Impairments
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the FOTO Low Back FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients With Lower Extremity Functional Status Deficit
Description: Percentage of patients aged 18 years or older with a functional deficit related to the lower extremity who achieve a Minimal Clinically Important Difference (MCID) in Lower Extremity Functional Scale (LEFS) score that indicates a functional improvement greater than zero. Two rates will be reported: • The overall proportion of patients achieving an MCID in LEFS change score. • The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via LEFS) proportion is greater than zero. The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the FOTO Lower Extremity Physical Function (LEPF) patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients With Neck Functional Status Deficit
Description: Percentage of patients aged 18 years or older with a functional deficit related to the neck who achieve a Minimal Clinically Important Difference (MCID) in the Neck Disability Index (NDI) or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported: • The overall proportion of patients achieving an MCID in NDI change score. • The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via NDI or equivalent tool) proportion is greater than zero. The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Neck Impairments
Description: This is a patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with neck impairments. The change in functional status (FS) is assessed using the FOTO Neck FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static/paper-pencil).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Shoulder Impairments
Description: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the FOTO Shoulder FS patient-reported outcome measure (PROM). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients With Upper-limb Functional Status Deficit
Description: Percentage of patients aged 13 years or older with a functional deficit related to the upper-limb who achieve a Minimal Clinically Important Difference (MCID) in QuickDASH or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported: • The overall proportion of patients achieving an MCID in QuickDASH change score. • The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via QuickDASH or equivalent tool) proportion is greater than zero. The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Change for Patients with Vestibular Dysfunction
Description: Percentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) as measured via the validated Dizziness Handicap Inventory or equivalent instrument to indicate functional, emotional, and physical improvement · Submission Age Criteria 1: Patients aged 14-17 years of age · Submission Age Criteria 2: Patients aged 18-64 years of age · Submission Age Criteria 3: Patients aged 65 years and older · Submission Criteria 4: Overall total rate of patients aged 14 years and older The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
High Priority: YES
Linked ICD-10 Codes:
Functional Status Changes for Patients with Upper or Lower Extremity Regional Swelling
Description: This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ with lymphedema or other causes of regional swelling. For patients with such conditions affecting the leg, foot, groin, or lower trunk regions, the change in FS is assessed using the FOTO Lower Extremity Regional Swelling (LERS) FS PROM. For patients with such conditions affecting the arm, hand, chest, or breast body regions, the change in FS is assessed using the FOTO Upper Extremity Regional Swelling (UERS) FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure (PM) at the patient level, individual clinician level, and clinic level to assess quality. Free public access is available at https://www.fotoinc.com/science-of-foto/nqf-measure-specifications.
High Priority: YES
Linked ICD-10 Codes:
Glaucoma – Intraocular Pressure Reduction
Description: Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis.
High Priority: YES
Linked ICD-10 Codes:
Glycemic management services
Description: For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having: For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that: a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, andb) Is reassessed at least annually.The performance threshold will increase to 75 percent for the second performance year and onward.Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Glycemic Referring Services
Description: For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.
High Priority: NO
Linked ICD-10 Codes:
Glycemic Screening Services
Description: For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.
High Priority: NO
Linked ICD-10 Codes:
Gout: Serum Urate Target
Description: The percentage of patients aged 18 and older with at least one clinician encounter (including telehealth) during the measurement period and a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.0 mg/dL.
High Priority: YES
Linked ICD-10 Codes:
Hammer Toe Outcome
Description: Percentage of patients with a who have a lesser toe deformity (hammer and claw toes) causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention
High Priority: YES
Linked ICD-10 Codes:
Health Information Exchange(HIE) Bi-Directional Exchange
Description: The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.
High Priority: NO
Linked ICD-10 Codes:
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.
High Priority: NO
Linked ICD-10 Codes:
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.
High Priority: NO
Linked ICD-10 Codes:
Heart Failure: Patient Self Care Education
Description: Percentage of patients aged >=18 years with a diagnosis of heart failure who were provided with self-care education on >=3 elements of education during >=1 visit within a 12-month period
High Priority: YES
Linked ICD-10 Codes:
Heel Pain Treatment Outcomes for Adults
Description: Percentage of patients aged 18 and older with a diagnosis of heel pain who receive an intervention intended to treat the heel pain and experience a clinically significant decrease in heel pain. Patients who have had at least two visits during the reporting period
High Priority: YES
Linked ICD-10 Codes:
Heel Pain Treatment Outcomes for Pediatric Patients
Description: Percentage of patients aged 6 to 18 years with a diagnosis of heel pain who receive an intervention intended to treat the heel pain and experience a clinically significant decrease in heel pain. Patients who have had at least two visits during the reporting period
High Priority: YES
Linked ICD-10 Codes:
Helicobacter pylori Status and Turnaround Time
Description: Percentage of stomach biopsy cases with gastritis that address the presence or absence of Helicobacter pylori AND meet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 2 business days). INSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score: 1. Percent of cases in which presence or absence of Helicobacter pylori is addressed. 2. Percent of cases that meet the maximum 2 business day turnaround time. The overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator 1 + Denominator 2).
High Priority: YES
Linked ICD-10 Codes:
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
Description: Percentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart.
High Priority: NO
Linked ICD-10 Codes:
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow
Description: Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.
High Priority: NO
Linked ICD-10 Codes:
Hemodialysis Access Creation
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Hemodialysis Access Creation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Hepatitis B Safety Screening
Description: If a patient is newly initiating biologic or new synthetic DMARD therapy, then the medical record should indicate appropriate screening for hepatitis B in the preceding 12 month period.
High Priority: YES
Linked ICD-10 Codes:
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Description: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period.
High Priority: NO
Linked ICD-10 Codes:
Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
Description: Percentage of patients undergoing a hip arthroplasty with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g. NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure.
High Priority: YES
Linked ICD-10 Codes:
Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk Evaluation
Description: Percentage of patients undergoing a hip arthroplasty who are evaluated for the presence or absence of cardiovascular risk factors within 30 days prior to the procedure (e.g. history of deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), arrhythmia, and stroke).
High Priority: YES
Linked ICD-10 Codes:
Hip/Knee Arthroplasty: Unplanned Readmission within 90 Days Following the Primary Procedure
Description: Percentage of patients 18+ who underwent a primary Total Hip Arthroplasty or Total Knee Arthroplasty and who had an unplanned 90-day readmission.
High Priority: YES
Linked ICD-10 Codes:
Hip/Knee Replacement: Postoperative Ambulation
Description: Adult patients 18+ undergoing a total hip or total knee replacement who ambulated postoperatively.
High Priority: YES
Linked ICD-10 Codes:
HIV Medical Visit Frequency
Description: Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.
High Priority: YES
Linked ICD-10 Codes:
HIV Screening
Description: Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.
High Priority: NO
Linked ICD-10 Codes:
HIV Viral Load Suppression
Description: The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
High Priority: YES
Linked ICD-10 Codes:
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
Description: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection.
High Priority: NO
Linked ICD-10 Codes:
Hospital admissions/complications within 30 days of TRUS Biopsy
Description: Percentage of patients who had TRUS biopsy performed who had ≥24h after the biopsy): infection, hematuria, new antibiotic Rx after biopsy, or inpatient consultation within 30 days
High Priority: YES
Linked ICD-10 Codes:
Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups
Description: This measure is a re-specified version of the measure, “Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition” (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group’s readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.
High Priority: YES
Linked ICD-10 Codes:
Hypertension Control (Stage 1 or 2)
Description: Proportion of patients with hypertension who had adequately controlled blood pressure
High Priority: YES
Linked ICD-10 Codes:
Hypotension Prevention After Spinal Placement for Elective Cesarean Section
Description: Percentage of patients, who present for elective Caesarean section under spinal anesthesia who have phenylephrine infusions started prophylactically to prevent hypotension.
High Priority: YES
Linked ICD-10 Codes:
Idiopathic Intracranial Hypertension: Improvement of mean deviation or stability of mean deviation
Description: Percentage of patients with improvement in mean deviation or stability of mean deviation (+1db) within 6 months of initiating therapy.
High Priority: YES
Linked ICD-10 Codes:
Immunization Registry Reporting
Description: The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
High Priority: NO
Linked ICD-10 Codes:
Immunization Registry Reporting Exclusion
Description: Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Immunization Registry Reporting for Multiple Registry Engagement
Description: Report as true if active engagement with more than one immunization registry in accordance with PI_PHCDRR_1.
High Priority: NO
Linked ICD-10 Codes:
Immunizations for Adolescents
Description: The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.
High Priority: NO
Linked ICD-10 Codes:
Implementation of an ASP
Description: Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: - Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.- Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). - Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.- Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. - Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.- Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.- Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. - Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions. - Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.- Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship guidance
High Priority: NO
Linked ICD-10 Codes:
Implementation of analytic capabilities to manage total cost of care for practice population
Description: In order to receive credit for this activity, a MIPS eligible clinician must conduct or build the capacity to conduct analytic activities to manage total cost of care for the practice population. Examples of these activities could include:1.) Train appropriate staff on interpretation of cost and utilization information;2.) Use available data regularly to analyze opportunities to reduce cost through improved care. An example of a platform with the necessary analytic capability to do this is the American Society for Gastrointestinal (GI) Endoscopy's GI Operations Benchmarking Platform.
High Priority: NO
Linked ICD-10 Codes:
Implementation of co-location PCP and MH services
Description: Integration facilitation and promotion of the colocation of mental health and substance use disorder services in primary and/or non-primary clinical care settings.
High Priority: NO
Linked ICD-10 Codes:
Implementation of condition-specific chronic disease self-management support programs
Description: Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community.
High Priority: NO
Linked ICD-10 Codes:
Implementation of documentation improvements for practice/process improvements
Description: Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).
High Priority: NO
Linked ICD-10 Codes:
Implementation of episodic care management practice improvements
Description: Provide episodic care management, including management across transitions and referrals that could include one or more of the following:Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/orManaging care intensively through new diagnoses, injuries and exacerbations of illness.
High Priority: NO
Linked ICD-10 Codes:
Implementation of fall screening and assessment programs
Description: Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).
High Priority: NO
Linked ICD-10 Codes:
Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
Description: Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following, such as:- Participation in multisource feedback; - Train all staff in quality improvement methods;- Integrate practice change/quality improvement into staff duties;- Engage all staff in identifying and testing practices changes;- Designate regular team meetings to review data and plan improvement cycles;- Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;- Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;- Participation in Bridges to Excellence;- Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.
High Priority: NO
Linked ICD-10 Codes:
Implementation of improvements that contribute to more timely communication of test results
Description: Timely communication of test results defined as timely identification of abnormal test results with timely follow-up.
High Priority: NO
Linked ICD-10 Codes:
Implementation of Integrated Patient Centered Behavioral Health Model
Description: Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following: - Use evidence-based treatment protocols and treatment to goal where appropriate;- Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;- Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;- Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;- Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;- Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or- Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.
High Priority: NO
Linked ICD-10 Codes:
Implementation of medication management practice improvements
Description: Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/orConduct periodic, structured medication reviews.
High Priority: NO
Linked ICD-10 Codes:
Implementation of methodologies for improvements in longitudinal care management for high risk patients
Description: Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/orUse on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.
High Priority: NO
Linked ICD-10 Codes:
Implementation of practices/processes for developing regular individual care plans
Description: Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient's goals and priorities, as well as desired outcomes of care.
High Priority: NO
Linked ICD-10 Codes:
Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
Description: Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.
High Priority: NO
Linked ICD-10 Codes:
Improved Access Site Bleeding
Description: Improved Access Site Bleeding is the percentage of interventions for patients with ESRD and a vascular access site that presented for prolonged bleeding, and who post-intervention reported a reduction in bleeding
High Priority: YES
Linked ICD-10 Codes:
Improved Practices that Disseminate Appropriate Self-Management Materials
Description: Provide self-management materials at an appropriate literacy level and in an appropriate language.
High Priority: NO
Linked ICD-10 Codes:
Improved Practices that Engage Patients Pre-Visit
Description: Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient's appointment.
High Priority: NO
Linked ICD-10 Codes:
Improved visual acuity after epiretinal membrane treatment within 120 days
Description: Percentage of patients with a 20% improvement in visual acuity within 120 days following epiretinal membrane treatment
High Priority: YES
Linked ICD-10 Codes:
Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days
Description: Percentage of patients with a 20% or greater improvement in visual acuity within 120 days following vitrectomy for complications of diabetic retinopathy
High Priority: YES
Linked ICD-10 Codes:
Improvement of Macular Edema in Patients with Uveitis
Description: Percentage of patients with uveitis and macular edema with a reduction of 20% or greater in the central subfield thickness on OCT within 90 days after treatment.
High Priority: YES
Linked ICD-10 Codes:
Improvement or Maintenance of Functioning for Individuals with a Mental Health and/or Substance Use Disorder
Description: The percentage of individuals aged 18 and older with a mental and/or substance use disorder who demonstrated an improvement in functioning (or maintained baseline level of functioning) based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) 180 days (+/- 30 days) after a baseline visit.
High Priority: YES
Linked ICD-10 Codes:
Incidental Coronary Artery Calcification Reported on Chest CT
Description: Percentage of final reports for male patients aged 18 years through 50 and female patients aged 18 through 65 years undergoing noncardiac noncontrast chest CT exams or with and without contrast chest CT exams that note presence or absence of coronary artery calcification or not evaluable
High Priority: YES
Linked ICD-10 Codes:
Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
Description: Infection rate following CIED device implantation, replacement, or revision.
High Priority: YES
Linked ICD-10 Codes:
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
Description: Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.
High Priority: NO
Linked ICD-10 Codes:
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Description: Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis.b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.
High Priority: YES
Linked ICD-10 Codes:
Initiation of the Initial Sepsis Bundle
Description: Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle
High Priority: NO
Linked ICD-10 Codes:
Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Inpatient COPD Exacerbation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient treatment for an acute exacerbation of COPD during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 60 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Integration of patient coaching practices between visits
Description: Provide coaching between visits with follow-up on care plan and goals.
High Priority: NO
Linked ICD-10 Codes:
Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism
Description: Percentage of final reports for patients aged 18 years and older undergoing CT pulmonary angiography (CTPA) with a finding of PE that specify the branching order level of the most proximal level of embolus (i.e. main, lobar, interlobar, segmental, sub segmental)
High Priority: YES
Linked ICD-10 Codes:
Intracranial Hemorrhage or Cerebral Infarction
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries hospitalized for cerebral infarction or intracranial hemorrhage during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Intraocular Pressure Reduction Following Laser Trabeculoplasty
Description: Percentage of patients who underwent laser trabeculoplasty who had IOP reduced by 20% or more from their pretreatment IOP or had a reduction in overall number of glaucoma medications.
High Priority: YES
Linked ICD-10 Codes:
Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure
Description: Percentage of patients who underwent trabeculectomy or aqueous shunt procedure who had IOP reduced by 20% or more from their pretreatment between 3 and 4 months of treatment or a reduction in overall number of glaucoma medications.
High Priority: YES
Linked ICD-10 Codes:
Intraoperative Antibiotic Redosing
Description: Percentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision (if fluoroquinolone or vancomycin, two hours) and undergo a procedure greater than two hours duration who received intraoperative antibiotic redosing at a maximum interval of two half-lives of the selected prophylactic antibiotic.
High Priority: YES
Linked ICD-10 Codes:
Intraoperative Hypotension among Non-Emergent Noncardiac Surgical Cases
Description: Percentage of general anesthesia cases in which mean arterial pressure (MAP) fell below 65 mmHg for cumulative total of 15 minutes or more
High Priority: YES
Linked ICD-10 Codes:
Invasive Procedure or Surgery Anticoagulation Medication Management
Description: For an anticoagulated patient undergoing a planned invasive procedure for which interruption in anticoagulation is anticipated, including patients taking vitamin K antagonists (warfarin), target specific oral anticoagulants (such as apixaban, dabigatran, and rivaroxaban), and heparins/low molecular weight heparins, documentation, including through the use of electronic tools, that the plan for anticoagulation management in the periprocedural period was discussed with the patient and with the clinician responsible for managing the patient’s anticoagulation. Elements of the plan should include the following: discontinuation, resumption, and, if applicable, bridging, laboratory monitoring, and management of concomitant antithrombotic medications (such as antiplatelets and nonsteroidal anti-inflammatory drugs (NSAIDs)). An invasive or surgical procedure is defined as a procedure in which skin or mucous membranes and connective tissue are incised, or an instrument is introduced through a natural body orifice.
High Priority: NO
Linked ICD-10 Codes:
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
Description: The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:• Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND• Most recent tobacco status is Tobacco Free -- AND• Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND• Statin Use Unless Contraindicated
High Priority: YES
Linked ICD-10 Codes:
IVC Filter Management Confirmation
Description: Percentage of final reports for eligible exams where an IVC filter is present and the radiologist included a statement of recommendation in the impression of the report for the treating clinician to: 1) Assess if there is a management plan in place for the patient’s IVC filter, AND 2) If there is no established management plan for the patient’s IVC filter, refer the patient to an interventional clinician on a nonemergent basis for evaluation.
High Priority: YES
Linked ICD-10 Codes:
Kidney Stones: Alpha-blockers at discharge for patients undergoing ureteroscopy or shockwave lithotripsy
Description: Percentage of patients who underwent ureteroscopy or shockwave lithotripsy and received alpha-blockers at discharge
High Priority: NO
Linked ICD-10 Codes:
Kidney Stones: ED visit within 30 days of ureteroscopy
Description: Percentage of patients who underwent ureteroscopy and experienced an unplanned ED visit within 30 days of the procedure
High Priority: YES
Linked ICD-10 Codes:
Kidney Stones: Opioid utilization after ureteroscopy and shockwave lithotripsy
Description: Percentage of patients who underwent ureteroscopy or shockwave lithotripsy and are discharged on NSAIDS, Acetaminophen, or "Other" and who were not prescribed opioids for pain control
High Priority: YES
Linked ICD-10 Codes:
Kidney Stones: Post-ureteroscopy and shockwave lithotripsy imaging for any stones
Description: Percentage of patients who underwent imaging within 60 days after ureteroscopy or shockwave lithotripsy
High Priority: NO
Linked ICD-10 Codes:
Kidney Stones: Readmission within 30 days of ureteroscopy
Description: Percentage of patients who underwent ureteroscopy and experienced a readmission within 30 days of the procedure
High Priority: YES
Linked ICD-10 Codes:
Kidney Stones: SWL in patients with largest renal stone > 2 cm or lower pole stone > 1 cm
Description: Percentage of patients who underwent shockwave lithotripsy with a largest renal stone > 2 cm or with a lower pole stone > 1 cm
High Priority: NO
Linked ICD-10 Codes:
Knee Arthroplasty
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo an elective knee arthroplasty during the performance period. Includes costs of services clinically related to the attributed clinician’s role in managing care from 30 days prior to the knee arthroplasty that triggers the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Known or Suspected Difficult Airway Mitigation Strategies
Description: Percentage of patients with a known or suspected difficult airway who undergo a planned general endotracheal anesthetic that have both a second provider present at the induction and placement of the endotracheal tube and have difficult airway equipment in the room prior to the induction.
High Priority: YES
Linked ICD-10 Codes:
Labor Epidural Failure when Converting from Labor Analgesia to Cesarean Section Anesthesia
Description: The percentage of patients who have pre-existing labor epidural or combined epidural/spinal technique who require either repeat procedural epidural or spinal, general anesthesia, or supplemental sedation as defined below for cesarean section.
High Priority: YES
Linked ICD-10 Codes:
Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
Description: Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/orIncorporate population health, quality and patient experience metrics in regular reviews of practice performance.
High Priority: NO
Linked ICD-10 Codes:
Leg Pain After Lumbar Discectomy/Laminectomy
Description: For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS Pain scale at three months (6 to 20 weeks) postoperatively.
High Priority: YES
Linked ICD-10 Codes:
Leg Pain After Lumbar Fusion
Description: For patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively. * hereafter referred to as VAS Pain.
High Priority: YES
Linked ICD-10 Codes:
Limit quantity of opioids prescribed for pain management in patients following Mohs micrographic surgery
Description: Percentage of patients prescribed opioids for pain management following Mohs surgery who received ten or fewer pills.
High Priority: YES
Linked ICD-10 Codes:
Lower Gastrointestinal Hemorrhage (groups only)
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lower Gastrointestinal Hemorrhage episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 35 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo surgery for lumbar spine fusion during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Lumpectomy Partial Mastectomy, Simple Mastectomy
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lumpectomy, Partial Mastectomy, Simple Mastectomy episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo partial or total mastectomy for breast cancer during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Lung Cancer Reporting (Biopsy/Cytology Specimens)
Description: Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.
High Priority: YES
Linked ICD-10 Codes:
Lung Cancer Reporting (Resection Specimens)
Description: Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.
High Priority: YES
Linked ICD-10 Codes:
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)
Description: Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at < 39 weeks of gestation completed who had elective deliveries by cesarean section (C-section), or early inductions of labor, without medical indication.
High Priority: YES
Linked ICD-10 Codes:
Maternity Care: Postpartum Follow-up and Care Coordination
Description: Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 8 weeks of giving birth and received the following at the postpartum visit: breast-feeding evaluation and education, postpartum depression screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.
High Priority: YES
Linked ICD-10 Codes:
MDD prevention and treatment interventions
Description: Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.
High Priority: NO
Linked ICD-10 Codes:
Measurement and Improvement at the Practice and Panel Level
Description: Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, that could include one or more of the following:- Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group (panel); and/or - Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level.
High Priority: NO
Linked ICD-10 Codes:
Measurement-based Care Processes: Baseline Assessment, Monitoring and Treatment Adjustment
Description: Percentage of individuals 18 years of age and older with a diagnosis of mental and/or substance abuse disorder, who had a baseline assessment with ongoing monitoring, AND who had an adjustment to their care plan following assessment and monitoring. Three rates are reported. a. Percentage of individuals who had a baseline assessment in at least five (5) mental health domains including depression, anxiety, substance use, suicide risk and psychosis, as well as an assessment of functioning and recovery. b. Percentage of individuals who had a baseline assessment, who were monitored with follow-up for improvement or maintenance of symptom severity, functioning and recovery. c. Percentage of individuals who had a baseline assessment AND who had documentation of a clinical decision to adjust (or no adjustment) their care plan, including an adjustment to their medication OR therapy; OR referral OR consultation, following monitoring.
High Priority: NO
Linked ICD-10 Codes:
Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure
Description: Bice-Boxerman Continuity of Care Primary Care Physician Measure. At a patient-level, Bice-Boxerman Continuity of Care Primary Care Physician Measure is a measure that considers the dispersion of primary care visits across providers, such that patients with higher scores have most of their primary care visits to the same provider or a small number of providers while those lower scores see a larger number providers. Formally, an individual Bice-Boxerman Continuity of Care score is calculated as follows: Bice-Boxerman Continuity of Care =(∑_(i=1)^k n_i^2 -N)/(N(N-1)) (1) where k is the number of providers, n_i is the number of visits to provider i, and N is the total number of visits. (Note that it is necessary that the patient has at least two visits.) We will calculate the physician-level continuity measure for all patients as follows: Bice-Boxerman Continuity of Care-PC=(∑_1^k 〖((Bice-Boxerman Continuity of Care)(n_k ))〗)/(N*(n_k)) (2) Where Bice-Boxerman Continuity of Care is the individual patient continuity score, n is number of total primary care visits for patient k during the study period, and N is the total number of patients seen by the physicians during the study period. This approach gives greater weight to patients with more visits.
High Priority: YES
Linked ICD-10 Codes:
Medicare Spending Per Beneficiary (MSPB)
Description: The risk-adjusted cost to Medicare for all Parts A and B services performed for an inpatient beneficiary as a result of a clinician's care during the period 3 days prior to the patient's hospital stay through 30 days after discharge.
High Priority: NO
Linked ICD-10 Codes:
Medication Management for People with Asthma
Description: The percentage of patients 5-64 years of age during the performance period who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period.
High Priority: YES
Linked ICD-10 Codes:
Medication Prescribed For Acute Migraine Attack
Description: Percentage of patients age 6 years and older with a diagnosis of migraine who were prescribed a guideline recommended or FDA approved/cleared treatment for acute migraine attacks within the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Melanoma Reporting
Description: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate.
High Priority: YES
Linked ICD-10 Codes:
Melanoma: – Appropriate Surgical Margins
Description: Percentage of primary excisional surgeries for melanoma or melanoma in situ with Breslow depth and appropriate surgical margins per the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology- Melanoma (NCCN Guideline).
High Priority: YES
Linked ICD-10 Codes:
Melanoma: Continuity of Care – Recall System
Description: Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:• A target date for the next complete physical skin exam, AND• A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment.
High Priority: YES
Linked ICD-10 Codes:
Melanoma: Coordination of Care
Description: Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.
High Priority: YES
Linked ICD-10 Codes:
Migraine Preventive Therapy Management
Description: Percentage of patients aged 6 years and older with a diagnosis of migraine whose migraine frequency is greater than or equal to 6 days per month/4 attacks per month who were managed with an evidence-based preventive migraine therapy, including therapies prescribed by another clinician.
High Priority: NO
Linked ICD-10 Codes:
MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
Description: MIPS eligible clinician leadership in clinical trials, research alliances or community-based participatory research (CBPR) that identify tools, research or processes that can focuses on minimizing disparities in healthcare access, care quality, affordability, or outcomes.
High Priority: NO
Linked ICD-10 Codes:
Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma
Description: Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both
High Priority: YES
Linked ICD-10 Codes:
Multimodal Pain Management
Description: Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain medicine.
High Priority: YES
Linked ICD-10 Codes:
Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)
Description: Weighted average of 3 former QCDR measures, ACRad 31, ACRad 32, Acrid 33.
High Priority: YES
Linked ICD-10 Codes:
Myocardial Perfusion Imaging (MPI) or Stress Echocardiography Imaging Studies - Adequate Exercise Protocol
Description: This is a multi-strata measure consisting of the following strata: 1. Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography studies using a Stress Test Type that includes exercise performed on patients 18 years of age or older. 2 .Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) or Stress Echocardiography exercise studies where the stress heart rate >= 85% of maximum heart rate and three or more minutes of exercise performed on patients 18 years of age or older. The overall performance will be calculated using a weighted average.
High Priority: NO
Linked ICD-10 Codes:
Myocardial Perfusion Imaging (MPI) or Stress Echocardiography imaging studies - Improving Image Quality
Description: This is a multi-strata measure consisting of the following strata: 1. Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies using Attenuation Correction performed on patients 18 years of age or older. 2.Percentage of SPECT-MPI or Stress Echocardiography imaging studies where the Imaging Protocol was appropriate for morbidly obese patients 18 years of age or older. The overall performance will be calculated using a weighted average.
High Priority: NO
Linked ICD-10 Codes:
Myocardial Perfusion Imaging (MPI) studies - Radiation Reduction Strategies
Description: This is a multi-strata measure consisting of the following strata: 1. Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies where the imaging protocol used was stress only performed on patients 18 years of age or older. 2. Percentage of Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging (MPI) studies where 9 or less millisieverts of radiation were administered per ASNC guideline recommendations on patients 18 years of age or older. The overall performance will be calculated using a weighted average.
High Priority: YES
Linked ICD-10 Codes:
Myocardial Perfusion Imaging (MPI) Studies, Transthoracic Echo (TTE), or Stress Echocardiography Imaging Studies - Adequate Reporting for Appropriate Interventions
Description: This is a multi-strata measure consisting of the following strata: 1. Percentage of Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) studies that were abnormal and contained perfusion defects documentation including location, severity, and size performed on patients 18 years of age or older. 2. Percentage of Single Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI), transthoracic echocardiography, or stress echocardiography imaging studies where the Left Ventricle Ejection Fraction (LVEF) was calculated and included in the report performed on patients 18 years of age or older. The overall performance will be calculated using a weighted average.
High Priority: YES
Linked ICD-10 Codes:
Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential
Description: Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by severity of arterial disease (as measured via ABI, perfusion pressure, or transcutaneous oximetry) . There are four rates reported for this measure. The four rates will be risk stratified into three buckets which are the following: 1. No evidence of arterial disease and ischemia is not a contributor to non-healing 2. Possible arterial compromise (possible reduced flow), but the patient may still be able to heal the wound(s) or ulcer(s) and does not require referral to a vascular specialist. 3. Evidence of arterial disease- patient should be referred to specialist for vascular assessment if not currently in the care of a vascular expert. Ischemia may be the reason the patient has failed to heal. 4. The average of the three risk stratified buckets which will be the performance rate in the JSON XML submitted.
High Priority: NO
Linked ICD-10 Codes:
Non-Emergent Coronary Artery Bypass Graft (CABG)
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Non-Emergent CABG episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo a CABG procedure during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Non-Muscle Invasive Bladder Cancer: Early Surveillance Cystoscopy for Non-Muscle Invasive Bladder Cancer
Description: Percentage of patients who receive surveillance cystoscopy within 4 months of TURBT for bladder cancer
High Priority: NO
Linked ICD-10 Codes:
Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease
Description: Percentage of patients with T1 disease, that had a second TURBT within 6 weeks of the initial TURBT
High Priority: NO
Linked ICD-10 Codes:
Non-Recommended Cervical Cancer Screening in Adolescent Females
Description: The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer.
High Priority: YES
Linked ICD-10 Codes:
Non-small cell lung carcinoma (NSCLC) ancillary biomarker testing status and turnaround time (TAT) from point of specimen accession date to ancillary biomarker testing completion and reporting date should be ≤ 10 days
Description: Percentage of lung cytopathology or pathology specimen cases with non-small cell lung carcinoma (NSCLC) that address presence or absence of actionable targets through ancillary biomarker testing AND meet the maximum 10 day turnaround time (TAT) requirement (Report Date of ancillary biomarker testing – Accession Date = ≤ 10 days). This measure has two performance rates that contribute to the overall performance score: 1. Percent of cases in which ancillary biomarker testing for actionable targets with a diagnosis of non-small cell carcinoma is addressed. 2. Percent of cases that meet the maximum 10 day turnaround time. The overall performance score submitted is a weighted average of: (Numerator 1 + Numerator 2)/(Denominator)
High Priority: NO
Linked ICD-10 Codes:
Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitis
Description: Percentage of ordering providers who ordered an amylase test in greater than 10% of their patients for the evaluation of a patient with acute pancreatitis, who were informed by the laboratory this test is not beneficial for the diagnosis of pancreatitis.
High Priority: NO
Linked ICD-10 Codes:
Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI)
Description: Percentage of ordering providers who have ordered a myoglobin or CK-MB for greater than 10% of the patients who have a diagnosis of suspected AMI, that were informed by the laboratory these tests are not beneficial for patients with a diagnosis of suspected AMI.
High Priority: NO
Linked ICD-10 Codes:
Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorder
Description: Percentage of ordering providers who ordered thyroid screening tests other than only a TSH in greater than 10% of their patients for the evaluation of a patient with suspected non-neoplastic thyroid disease, who were informed by the laboratory these tests are not beneficial for the initial diagnosis of thyroid disease.
High Priority: NO
Linked ICD-10 Codes:
Notification to the provider ordering repeat blood chemistry panels in clinically stable patients within four days.
Description: Percentage of providers who ordered a repeat blood chemistry panel within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.
High Priority: NO
Linked ICD-10 Codes:
Notification to the provider ordering repeat C. difficile stool toxin testing within seven days
Description: Percentage of providers who ordered repeat C. difficile stool toxin testing within seven days on an individual patient, who were notified by the laboratory that repeat testing is not beneficial, and can lead to increased false positive test results.
High Priority: NO
Linked ICD-10 Codes:
Notification to the provider ordering repeat CBCs in clinically stable patients within four days
Description: Percentage of providers who ordered a repeat CBC within four days on an individual patient, in greater than 10% of their patients tested, who were notified by the laboratory that repeat testing is not likely beneficial in clinically stable patients.
High Priority: NO
Linked ICD-10 Codes:
Notification to the provider ordering repeat Hepatitis C serology testing on a patient with previously positive results
Description: Percentage of providers who ordered repeat Hepatitis C serology testing on a patient with previously positive results, who were notified by the laboratory that repeat testing is not beneficial.
High Priority: NO
Linked ICD-10 Codes:
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
Description: Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed.
High Priority: YES
Linked ICD-10 Codes:
Obstructive Sleep Apnea: Mitigation Strategies
Description: Percentage of patients aged 18 years or older, who undergo an elective procedure requiring anesthesia services who are screened for obstructive sleep apnea (OSA) AND, if positive, for whom two or more selected mitigation strategies was used prior to PACU discharge
High Priority: YES
Linked ICD-10 Codes:
Obstructive Sleep Apnea: Patient Education
Description: Percentage of patients aged 18 years or older, who undergo an elective procedure requiring anesthesia services who are screened for obstructive sleep apnea (OSA) AND, if positive, have documentation that they received education regarding their risk for OSA prior to PACU discharge
High Priority: NO
Linked ICD-10 Codes:
Obtaining Preoperative Nutritional Recommendations from a Registered Dietitian Nutritionist (RDN) in Nutritionally At-Risk Surgical Patients
Description: Percentage of patients age 18 years and older who have undergone a surgical procedure and were identified to be at-risk for malnutrition based on a malnutrition screening OR who were referred to a registered dietitian nutritionist or clinically qualified nutrition professional and have a preoperative nutrition assessment which was documented in the medical record along with documentation of any recommended nutrition interventions.
High Priority: NO
Linked ICD-10 Codes:
Offloading with Remote Monitoring
Description: Percentage of patients with a plantar foot ulcer who were compliant with offloading and healed their ulcer in 10 (ten) weeks.
High Priority: YES
Linked ICD-10 Codes:
ONC Direct Review Attestation
Description: I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.
High Priority: NO
Linked ICD-10 Codes:
ONC-ACB Surveillance Attestation
Description: I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.
High Priority: NO
Linked ICD-10 Codes:
Oncology: Advance Care Planning in metastatic cancer patients
Description: Percentage of patients with metastatic (stage 4) cancer who have a documented Advance Care Planning discussion in the first 6 months after metastatic diagnosis to inform treatment decisions and end-of-life care.
High Priority: YES
Linked ICD-10 Codes:
Oncology: Combination chemotherapy recommended or received within 4 months of diagnosis by women under 70 with AJCC stage T1cN0M0 to Stage 1B-III ER/PR negative breast cancer
Description: Percentage of female patients, age >18 at diagnosis, who have their first diagnosis of breast cancer (epithelial malignancy), at AJCC Stage T1cN0M0 (tumor greater than 1cm), or Stage 1B-III, whose primary tumor is progesterone and estrogen receptor negative recommended for multi-agent chemotherapy (recommended or administered) within 4 months (120 days) of diagnosis
High Priority: YES
Linked ICD-10 Codes:
Oncology: Hepatitis B serology testing and prophylactic treatment prior to receiving anti-CD20 targeting drugs
Description: Percentage of patients tested for Hepatitis B prior to receiving anti-CD20 targeting treatment, including rituximab, ofatumumab, and obinutuzumab; patients testing positive for Hepatitis B receive prophylactic treatment.
High Priority: YES
Linked ICD-10 Codes:
Oncology: Medical and Radiation – Pain Intensity Quantified
Description: Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.
High Priority: YES
Linked ICD-10 Codes:
Oncology: Medical and Radiation - Plan of Care for Pain
Description: Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
High Priority: YES
Linked ICD-10 Codes:
Oncology: Mutation testing for lung cancer completed prior to start of targeted therapy
Description: Proportion of stage 4 NSCLC patients tested for actionable biomarkers, including EGFR, BRAF mutation; ROS1, ALK rearrangement; PD-L1 expression, and received targeted therapy or chemotherapy based on biomarker results.
High Priority: YES
Linked ICD-10 Codes:
Oncology: Patient-reported pain improvement
Description: Percentage of cancer patients currently receiving chemotherapy or radiation therapy who report significant pain improvement (high to moderate, moderate to low, or high to low) within 30 days
High Priority: YES
Linked ICD-10 Codes:
Oncology: Supportive care drug utilization in last 14 days of life
Description: Percentage of patients receiving supportive care drugs (including colony stimulating factors, bone health, supplemental iron medications, and neurokinin 1 (NK1) receptor antagonist antiemetics) during the 14 days prior to and including the date of death.
High Priority: YES
Linked ICD-10 Codes:
Oncology: Utilization of GCSF in metastatic colorectal cancer
Description: Percentage of Stage 4 colon/rectal cancer patients receiving any white cell growth factors with chemotherapy
High Priority: YES
Linked ICD-10 Codes:
Oncology: Utilization of PET, PET/CT, or CT scans for breast cancer stage 0, I, or II at any time during the course of evaluation and treatment
Description: Percentage of female breast cancer patients stage 0, I, or II with curative treatment intent (including observation, adjuvant chemotherapy, radiation or surgery) who receive a PET, PET/CT or CT scan as part of initial staging, treatment, or routine surveillance
High Priority: YES
Linked ICD-10 Codes:
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
Description: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection.
High Priority: NO
Linked ICD-10 Codes:
Opening Pressure in Lumbar Puncture
Description: Percentage of final reports for patients aged ≥ 18 which include Documentation of Opening Pressure Value obtained during Lumbar Puncture
High Priority: NO
Linked ICD-10 Codes:
Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment
Description: Percentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication-Assisted Treatment and Referred to Outpatient Opioid Treatment
High Priority: YES
Linked ICD-10 Codes:
Optimal Asthma Control
Description: Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.
High Priority: YES
Linked ICD-10 Codes:
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
Description: Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).
High Priority: YES
Linked ICD-10 Codes:
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Description: Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.
High Priority: YES
Linked ICD-10 Codes:
Osteoporosis Management in Women Who Had a Fracture
Description: The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture.
High Priority: NO
Linked ICD-10 Codes:
Otitis Media with Effusion (OME): Avoidance of Inappropriate Use of Medications
Description: Percentage of patients age 2 months through 12 years with a diagnosis of otitis media with effusion who were not prescribed or recommended the use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy.
High Priority: YES
Linked ICD-10 Codes:
Otitis Media with Effusion: Hearing Test for Chronic OME > 3 months
Description: Percentage of patients age 6 months to 12 years of age at the time of the visit with a diagnosis of otitis media with effusion including chronic serous, mucoid, or nonsuppurative otitis media with effusion of ≥3 months duration who had audiometry performed, ordered or who were referred for an audiometric evaluation.
High Priority: NO
Linked ICD-10 Codes:
Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use
Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.
High Priority: YES
Linked ICD-10 Codes:
Outcome monitoring of ADHD functional impairment in children and youth
Description: Percentage of children aged 4 through 18 years, with a diagnosis of attention deficit/hyperactivity disorder (ADHD), who demonstrate a change score of 0.25 or greater on the Weiss Functional Impairment Rating Scale - Parent Report (WFIRS-P) within 2 to 10 months after an initial positive finding of functional impairment.
High Priority: YES
Linked ICD-10 Codes:
Outcomes of Hearing Loss Treatment
Description: Percentage of patients aged 50 years and older, who are screened with a hearing loss self-assessment tool that indicated an impact on hearing-related QoL AND if diagnosed with a mild or greater hearing loss in at least one ear or identified with a hearing loss, receive an audiologic care plan and hearing loss intervention(s) AND report a meaningful clinically important difference (MCID) improvement in hearing-related quality of life (QoL) within 12 months of hearing loss diagnosis.
High Priority: YES
Linked ICD-10 Codes:
Outcomes of Treatment of Benign Paroxysmal Positional Vertigo
Description: Percentage of patients aged 18 years and older, who report benign paroxysmal positional vertigo (BPPV)-related symptoms and are screened with a dizziness assessment questionnaire and undergo positional nystagmus testing AND, if diagnosed or identified with BPPV, received a BPPV-related care plan and vestibular intervention(s) or treatment(s) AND who have an improvement in nystagmus or report an improvement in BPPV-related symptoms, and report a meaningful clinically important difference (MCID) improvement of BPPV-related quality of life (QoL).
High Priority: YES
Linked ICD-10 Codes:
Outcomes of Treatment of Subjective Tinnitus
Description: Percentage of patients aged 18 years and older who are screened for bothersome subjective tinnitus AND, if patient reports symptoms, assessed with clinical evaluation for tinnitus severity and impact on hearing-related quality of life (HRQoL) using a validated self-assessment tool AND, if identified with tinnitus that impacts the patients HRQoL, receive a tinnitus-related care plan, and tinnitus-related intervention(s), treatment(s), or management AND who report a meaningful clinically important difference (MCID) improvement in the impact of tinnitus on the patient’s HRQoL within 12 months of initial identification.
High Priority: YES
Linked ICD-10 Codes:
Overuse of Imaging for the Evaluation of Primary Headache
Description: Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present.
High Priority: YES
Linked ICD-10 Codes:
p16 Immunohistochemistry Reporting for Human Papillomavirus in Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)
Description: Percentage of surgical pathology reports for invasive oropharyngeal squamous cell carcinoma (OPSCC) with quantitative p16 immunohistochemistry (IHC) using a ≥70% nuclear and cytoplasmic staining cutoff performed as a surrogate for HR-HPV status
High Priority: YES
Linked ICD-10 Codes:
Pain Brought Under Control Within 48 Hours
Description: Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours.
High Priority: YES
Linked ICD-10 Codes:
Pain Interference Response utilizing PROMIS
Description: The percentage of adult patients (18 years of age or older) who report chronic pain issues and demonstrated a response to treatment at one month from the index score
High Priority: YES
Linked ICD-10 Codes:
Parameters in stress echocardiography dobutamine testing for low flow, low gradient aortic stenosis
Description: Percentage of low flow, low gradient aortic stenosis studies in the setting of LVEF < 50% with complete measurements during a dobutamine stress echocardiogram on patients 18 years of age or older.
High Priority: NO
Linked ICD-10 Codes:
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease
Description: Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once in the past 12 months.
High Priority: NO
Linked ICD-10 Codes:
Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease
Description: Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms once in the past 12 months
High Priority: NO
Linked ICD-10 Codes:
Parkinson’s Disease: Rehabilitative Therapy Options
Description: Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed once in the past 12 months.
High Priority: YES
Linked ICD-10 Codes:
Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS or Other Similar Activity
Description: For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS® or the American Board of Family Medicine (ABFM) Performance in Practice Modules.
High Priority: NO
Linked ICD-10 Codes:
Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
Description: Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.
High Priority: NO
Linked ICD-10 Codes:
Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
Description: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
High Priority: NO
Linked ICD-10 Codes:
Participation in a QCDR, that promotes use of patient engagement tools.
Description: Participation in a Qualified Clinical Data Registry (QCDR), that promotes patient engagement, including:- Use of processes and tools that engage patients for adherence to treatment plans;- Implementation of patient self-action plans;- Implementation of shared clinical decision making capabilities; or- Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.
High Priority: NO
Linked ICD-10 Codes:
Participation in an AHRQ-listed patient safety organization.
Description: Participation in an AHRQ-listed patient safety organization.
High Priority: NO
Linked ICD-10 Codes:
Participation in CAHPS or other supplemental questionnaire
Description: Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).
High Priority: NO
Linked ICD-10 Codes:
Participation in Joint Commission Evaluation Initiative
Description: Participation in Joint Commission Ongoing Professional Practice Evaluation initiative
High Priority: NO
Linked ICD-10 Codes:
Participation in MOC Part IV
Description: In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.
High Priority: NO
Linked ICD-10 Codes:
Participation in Population Health Research
Description: Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.
High Priority: NO
Linked ICD-10 Codes:
Participation in private payer CPIA
Description: Participation in designated private payer clinical practice improvement activities.
High Priority: NO
Linked ICD-10 Codes:
Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
Description: User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provide substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.
High Priority: NO
Linked ICD-10 Codes:
Participation on Disaster Medical Assistance Team, registered for 6 months.
Description: Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.
High Priority: NO
Linked ICD-10 Codes:
Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery
Description: Percentage of patients age 18 and older undergoing a non-emergency risk modeled cardiac surgery procedure that had personalized risk assessment using the STS risk calculator and discussed those risks with the surgeon.
High Priority: YES
Linked ICD-10 Codes:
Patient Feedback of Test Results Following Cognitive or Mental Status Assessment
Description: Percentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback on test results directly to patient and/or their caregiver.
High Priority: YES
Linked ICD-10 Codes:
Patient Medication Risk Education
Description: In order to receive credit for this activity, MIPS eligible clinicians must provide both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use for patients who are prescribed both benzodiazepines and opioids. Education must be completed for at least 75% of qualifying patients and occur: (1) at the time of initial co-prescribing and again following greater than 6 months of co- prescribing of benzodiazepines and opioids, or (2) at least once per MIPS performance period for patients taking concurrent opioid and benzodiazepine therapy.
High Priority: NO
Linked ICD-10 Codes:
Patient Navigator Program
Description: Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.
High Priority: NO
Linked ICD-10 Codes:
Patient Reported Experience of Care: Wound Outcome
Description: All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period.
High Priority: YES
Linked ICD-10 Codes:
Patient reported falls and plan of care
Description: Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit
High Priority: YES
Linked ICD-10 Codes:
Patient Reported Health-Related Quality of Life (HRQoL) during Treatment for Advanced Cancer
Description: Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life. Two rates are reported: 1. Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart. 2. Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life.
High Priority: YES
Linked ICD-10 Codes:
Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers
Description: The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA by Nestlé) within the 12-month reporting period. Using the Self-MNA® by Nestlé, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician should subsequently create a follow up plan (e.g. diet enhancement and oral supplementation of 400 kcal/d2), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS 400-600 kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. Patients may be provided with a variety of options for supplementation from which to chose that would provide the recommended number of calories or nutritional content. A follow up plan is documented during the encounter from the patient reported nutritional assessment.
High Priority: NO
Linked ICD-10 Codes:
Patient Reported Outcome of late effects of radiation symptoms following treatment with Hyperbaric Oxygen Therapy (HBOT)
Description: The percentage of patients 18 or older undergoing 10 or more treatments with HBOT for late effects of radiation whose self reported symptoms improve by at least 2 categories on the appropriate questionnaire (e.g. the Hematuria classification scale, the Chandler grade, the Cystitis questionnaire, the Bowel questionnaire, the head and neck questionnaire).
High Priority: YES
Linked ICD-10 Codes:
Patient satisfaction following spinal fusion surgery
Description: Calculation of the percent of patients who are 'Very satisfied' or 'Somewhat satisfied' with their surgical outcome following a spine surgical intervention (cervical or lumbar).
High Priority: YES
Linked ICD-10 Codes:
Patient Satisfaction with Information Prior to Facial Reconstruction After Skin Cancer Resection Procedures
Description: Percentage of patients aged 18 and older who underwent facial reconstruction after skin cancer resection who responded to the (6 question) Face-Q Satisfaction with Information: Appearance Module within 60 days of the procedure and scored 15 (52%) or higher or if scored lower than 15 (52%) there is documentation of a provider call to the patient or follow-up visit within 30 days of completion of the tool
High Priority: YES
Linked ICD-10 Codes:
Patient Satisfaction with Information Provided during Breast Reconstruction
Description: Percentage of patients aged 18 years and older who had breast reconstruction who reported a score of 65 or higher on the BREAST-Q Satisfaction with Information scale, within 120 days of the procedure. This measure is reported as three rates stratified by procedure: •Reporting Criteria 1: Implant Breast Reconstruction Procedures •Reporting Criteria 2: Autologous Breast Reconstruction Procedures •Total Rate: All breast reconstruction Procedures
High Priority: YES
Linked ICD-10 Codes:
Patient Satisfaction with Rhinoplasty Procedure
Description: Percentage of patients aged 15 years and older who had a rhinoplasty procedure who demonstrated improvement* in functional and/or aesthetic satisfaction using a validated patient satisfaction tool (such as SCHNOS, NOSE, SNOT, RHINO) within a year following their procedure. *pre-test and post-test scores must be documented in the patient record
High Priority: YES
Linked ICD-10 Codes:
Patient-Centered Surgical Risk Assessment and Communication
Description: Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
High Priority: YES
Linked ICD-10 Codes:
Patient-Reported Experience with Anesthesia
Description: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. This measure will consist of two performance rates: AQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care AQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care NOTE: The measure requires that a valid survey, as defined in the numerator of AQI48a, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI48b, a minimum number of 20 surveys with the mandatory question completed must be reported. ** In order to be scored on this measure, clinicians must report BOTH AQI48a AND AQI48b.
High Priority: YES
Linked ICD-10 Codes:
Patient-Reported Pain and/or Function Improvement after ACLR Surgery
Description: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.
High Priority: YES
Linked ICD-10 Codes:
Patient-Reported Pain and/or Function Improvement after APM Surgery
Description: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary arthroscopic partial meniscectomy (APM) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.
High Priority: YES
Linked ICD-10 Codes:
Patient-Reported Pain and/or Function Improvement after Total Hip Arthroplasty
Description: Percentage of patients 18 years of age and older who obtained an improvement of at least 1 minimal clinically important difference (MCID) in hip pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total hip arthroplasty (THA) surgery. PROMs include any validated measures of hip-related pain and/or function with MCID thresholds supported by literature, including HOOS-Pain (24 points), HOOS-PS (23 points), and HOOS-JR (18 points).
High Priority: YES
Linked ICD-10 Codes:
Patient-Reported Pain and/or Function Improvement after Total Knee Arthroplasty
Description: Percentage of patients 18 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.
High Priority: YES
Linked ICD-10 Codes:
Patient-Reported Pain and/or Function Improvement after Total Shoulder Arthroplasty
Description: Percentage of patients 18 years of age and older who obtained an improvement of at least 1 minimal clinically important difference (MCIDO) in shoulder pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total shoulder arthroplasty (TSA) surgery. PROMs include any validated measures of shoulder-related pain and/or function with MCID thresholds supported by literature, including PSS (11.4 points) and ASES (13.6 points).
High Priority: YES
Linked ICD-10 Codes:
Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
Description: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies.
High Priority: YES
Linked ICD-10 Codes:
PCI Bleeding Campaign
Description: Participation in the PCI Bleeding Campaign which is a national quality improvement program that provides infrastructure for a learning network and offers evidence-based resources and tools to reduce avoidable bleeding associated with patients who receive a percutaneous coronary intervention (PCI).The program uses a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for PCI patients by implementing quality improvement strategies:- Radial-artery access,- Bivalirudin, and- Use of vascular closure devices.
High Priority: NO
Linked ICD-10 Codes:
PCR Test with MR2 or greater result (BCR-ABL1 transcript level <= 1% [IS]) for patients receiving TKI for at least 6 months for Chronic Myelogenous Leukemia
Description: Percentage of patients aged 18 and older with chronic myelogenous leukemia who are receiving TKI therapy for at least 6 months, who have at least 1 PCR test performed with the most recent result equal to or greater than MR2 (BCR-ABL1 transcript level <= 1% [IS]) during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Pediatric Medication reconciliation
Description: Percentage of pediatric patients who had a medication review at every encounter and a medication list present in the medical record.
High Priority: NO
Linked ICD-10 Codes:
Pediatric OSA: Objective Assessment of OSA Signs and Symptoms in Children with Complex Medical Conditions
Description: Proportion of patients aged < 18 years with complex medical conditions known to be at high risk for OSA and with signs and symptoms of OSA that underwent a PSG or were referred to a sleep specialist, otolaryngologist, or other specialist experienced in evaluation and management of OSA in children
High Priority: NO
Linked ICD-10 Codes:
Pediatric OSA: Objective Assessment of Positive Airway Pressure Therapy Adherence
Description: Proportion of patients aged < 18 years diagnosed with OSA that were prescribed positive airway pressure therapy and had documentation of objectively measured adherence to positive airway pressure therapy within 3 months of starting therapy
High Priority: NO
Linked ICD-10 Codes:
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy
Description: Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse.
High Priority: YES
Linked ICD-10 Codes:
Penicillin Allergy: Appropriate Removal or Confirmation
Description: Percentage of patients, regardless of age, with a primary diagnosis of penicillin or ampicillin/amoxicillin allergy, who underwent elective skin testing or antibiotic challenge that resulted in the removal of the penicillin or ampicillin/amoxicillin allergy label from the medical record if negative or confirmation of the penicillin or ampicillin/amoxicillin allergy label if positive. National Quality Strategy Domain: Communication and Care Coordination Outcome Measure
High Priority: YES
Linked ICD-10 Codes:
Percent of patients meeting SCB thresholds for back or neck pain
Description: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)
High Priority: YES
Linked ICD-10 Codes:
Percent of patients meeting SCB thresholds for leg or arm pain
Description: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in leg or arm pain following a spine surgical intervention (cervical or lumbar)
High Priority: YES
Linked ICD-10 Codes:
Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)
Description: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)
High Priority: YES
Linked ICD-10 Codes:
Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)
Description: Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.
High Priority: YES
Linked ICD-10 Codes:
Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)
Description: Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life.
High Priority: YES
Linked ICD-10 Codes:
Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)
Description: Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life.
High Priority: YES
Linked ICD-10 Codes:
Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate
Description: Percentage of clinically successful percutaneously created arteriovenous fistulae (pAVF) for patients aged 18 years and older on maintenance hemodialysis dialysis
High Priority: YES
Linked ICD-10 Codes:
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
Description: Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
High Priority: YES
Linked ICD-10 Codes:
Perioperative Anemia Management
Description: Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge.
High Priority: YES
Linked ICD-10 Codes:
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin
Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis.
High Priority: YES
Linked ICD-10 Codes:
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Description: Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.
High Priority: YES
Linked ICD-10 Codes:
Perioperative Temperature Management
Description: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
High Priority: YES
Linked ICD-10 Codes:
Peripheral Artery Disease: Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk
Description: Percentage of Patients 18-75 years of age with PAD who were offered moderate-to-high intensity statin
High Priority: NO
Linked ICD-10 Codes:
Peritoneal Dialysis Catheter Success Rate
Description: Percentage of clinically successful peritoneal dialysis (PD) catheter placements in patients aged 18 and older.
High Priority: YES
Linked ICD-10 Codes:
Person-Centered Primary Care Measure Performance Measure (PCPCM PRO-PM)
Description: The Person-Centered Primary Care Measure Performance Measure (PCPCM PRO-PM) utilizes the PCPCM PROM (a comprehensive and parsimonious set of 11 patient-reported items) to assess the broad scope of primary care: accessibility; comprehensive, whole person focus; integration of care across acute and chronic illness, prevention, mental health, and life events; coordinating care in a fragmented system; knowing the patient as a person; developing a relationship through key life events; advocacy; providing care in a family context; providing care in a community context; goal-oriented care; and, disease, illness, and prevention management. The PCPCM PRO-PM performance measure, generated from the patient reported instrument, goes beyond usual patient experience or satisfaction measures, to use the on-the-ground view of patients to assess elements of primary care missed by usual measures and gives clinicians a distinctive and comprehensive view from a patient’s perspective. 1. My practice makes it easy for me to get care. Definitely Mostly Somewhat Not at all 2. My practice is able to provide most of my care. Definitely Mostly Somewhat Not at all 3. In caring for me, my doctor considers all the factors that affect my health. Definitely Mostly Somewhat Not at all 4. My practice coordinates the care I get from multiple places. Definitely Mostly Somewhat Not at all 5. My doctor or practice knows me as a person. Definitely Mostly Somewhat Not at all 6. My doctor and I have been through a lot together. Definitely Mostly Somewhat Not at all 7. My doctor or practice stands up for me. Definitely Mostly Somewhat Not at all 8. The care I get takes into account knowledge of my family. Definitely Mostly Somewhat Not at all 9. The care I get in this practice is informed by knowledge of my community. Definitely Mostly Somewhat Not at all 10. Over time, my practice helps me to stay healthy. Definitely Mostly Somewhat Not at all 11. Over time, my practice helps me to meet my goals. Definitely Mostly Somewhat Not at all
High Priority: YES
Linked ICD-10 Codes:
Photodocumentation of Cecal Intubation
Description: The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination.
High Priority: NO
Linked ICD-10 Codes:
Physician’s Orders for Life-Sustaining Treatment (POLST) Form
Description: Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed
High Priority: YES
Linked ICD-10 Codes:
Pneumococcal Vaccination Status for Older Adults
Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
High Priority: NO
Linked ICD-10 Codes:
Population empanelment
Description: Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management. Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.
High Priority: NO
Linked ICD-10 Codes:
Post operative hypocalcemia after thyroidectomy surgery
Description: The number or percent of patients with low calcium levels or negligible parathyroid hormone values reported at 30 days or more post op
High Priority: YES
Linked ICD-10 Codes:
Post-operative opioid management following ocular surgery
Description: Percentage of patients aged 18 years and older who underwent ocular surgical procedures who were assessed for opioid use/requirements post-operatively, defined by either not receiving opioids post-operatively, receiving opioids for pain for 7 days or less post-operatively, or if expected to require opioids for more than 7 days after the surgical procedure, having an opioid use management plan documented.
High Priority: YES
Linked ICD-10 Codes:
Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children
Description: The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event AND with documentation of a standardized symptom monitor (PCL-5 for adults, CATS for child/adolescent) AND demonstrated a response to treatment at six months (+/- 120 days) after the index visit. This measure is a multi-strata measure, which addresses symptom monitoring for both child and adult patients being treated for post-traumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.
High Priority: YES
Linked ICD-10 Codes:
Practice Improvements for Bilateral Exchange of Patient Information
Description: Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following: - Participate in a Health Information Exchange if available; and/or - Use structured referral notes.
High Priority: NO
Linked ICD-10 Codes:
Practice Improvements that Engage Community Resources to Support Patient Health Goals
Description: Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: - Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.- Including through the use of tools that facilitate electronic communication between settings;- Screen patients for health-harming legal needs;- Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or- Provide a guide to available community resources.
High Priority: NO
Linked ICD-10 Codes:
Pre operative ultrasound exam of patients with thyroid cancer
Description: Documentation of use and efficacy of complete pre op cervical ultrasound exam in cancer patients
High Priority: NO
Linked ICD-10 Codes:
Pressure Ulcer* (PU) Healing or Closure for ulcers on the torso (body)
Description: Percentage of Stage 2, 3, or 4 pressure ulcers* (not on the lower extremity) among patients age 18 or older that achieve healing or closure within 6 months, stratified by the Wound Healing Index (WHI). Healing or closure may occur by delayed secondary intention or may be the result of surgical intervention (e.g. rotational flap or skin graft). Lower extremity pressure ulcers are not included in this measure because they commonly overlap with arterial and diabetic foot ulcers and require a separate risk stratification model.
High Priority: YES
Linked ICD-10 Codes:
Pressure Ulcers – Risk Assessment and Plan of Care
Description: Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed
High Priority: YES
Linked ICD-10 Codes:
Prevention of Arterial Line-Related Bloodstream Infections
Description: Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial catheter for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed. This measure will consist of two performance rates: a. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the brachial, radial, posterior tibial or dorsalis pedis artery for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed b. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the femoral or axillary artery for whom the arterial line was inserted with all indicated elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound technique is followed The overall measure score will be calculated as an average of the performance rates of part A and part B.
High Priority: YES
Linked ICD-10 Codes:
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
Description: Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
High Priority: YES
Linked ICD-10 Codes:
Prevention of Information Blocking Attestation
Description: I attest to CMS that I - (A) did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (B) Implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: (1) Connected in accordance with applicable law; (2) Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170; (3) Implemented in a manner that allowed for timely access by patients to their electronic health information; and (4) Implemented in a manner that allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated health care providers, and with disparate certified EHR technology and vendors. (C) Responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and other persons, regardless of the requestor's affiliation or technology vendor.
High Priority: NO
Linked ICD-10 Codes:
Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
Description: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively.
High Priority: YES
Linked ICD-10 Codes:
Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)
Description: Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.
High Priority: YES
Linked ICD-10 Codes:
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous 12 months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters.
High Priority: NO
Linked ICD-10 Codes:
Preventive Care and Screening: Influenza Immunization
Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
High Priority: NO
Linked ICD-10 Codes:
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Description: Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter.
High Priority: NO
Linked ICD-10 Codes:
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Description: Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is pre-hypertensive or hypertensive.
High Priority: NO
Linked ICD-10 Codes:
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user. Three rates are reported: a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user
High Priority: NO
Linked ICD-10 Codes:
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user.
High Priority: NO
Linked ICD-10 Codes:
Preventive Treatment Prescribed for Cluster Headache
Description: Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed short-term and/or long-term preventive treatment, including treatments prescribed by a different clinician.
High Priority: NO
Linked ICD-10 Codes:
Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients
Description: The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.
High Priority: NO
Linked ICD-10 Codes:
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Description: Percentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement period.
High Priority: NO
Linked ICD-10 Codes:
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Description: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.
High Priority: NO
Linked ICD-10 Codes:
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
Description: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period.
High Priority: YES
Linked ICD-10 Codes:
Prolonged Length of Stay Following Coronary Artery Bypass Grafting
Description: Percentage of patients aged 18 years and older undergoing isolated CABG with an inpatient postoperative length of stay of more than 14 days whether patient is alive or dead at discharge
High Priority: YES
Linked ICD-10 Codes:
Promote Use of Patient-Reported Outcome Tools
Description: Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PQH-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.
High Priority: NO
Linked ICD-10 Codes:
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Description: Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the bladder recognized either during or within 30 days after surgery.
High Priority: YES
Linked ICD-10 Codes:
Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
Description: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.
High Priority: YES
Linked ICD-10 Codes:
Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair
Description: Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery.
High Priority: YES
Linked ICD-10 Codes:
Prostate Cancer Gleason Pattern, Score, and Grade Group
Description: Percentage of surgical pathology reports for biopsies or radical resections (radical prostatectomy) of primary prostate cancer that include Gleason patterns used in determining the Gleason score, total Gleason score, and grade group classification
High Priority: YES
Linked ICD-10 Codes:
Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients
Description: Proportion of patients with low-risk prostate cancer receiving active surveillance or watchful waiting
High Priority: NO
Linked ICD-10 Codes:
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Description: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
High Priority: YES
Linked ICD-10 Codes:
Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer
Description: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate.
High Priority: NO
Linked ICD-10 Codes:
Prostate Cancer: Complications within 30 days of radical prostatectomy
Description: Percentage of radical prostatectomy patients who do not have any deviations from an uncomplicated recovery pathway within 30 days of the procedure
High Priority: YES
Linked ICD-10 Codes:
Prostate Cancer: Confirmation Testing in low risk AS eligible patients
Description: Percentage of low risk patients that are eligible for active surveillance who receive confirmation testing within 6 months of diagnosis
High Priority: NO
Linked ICD-10 Codes:
Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months
Description: Percentage of patients on active surveillance that have ≥ 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis
High Priority: NO
Linked ICD-10 Codes:
Prostate Cancer: Opioid utilization after radical prostatectomy
Description: Percentage of patients who underwent radical prostatectomy and are discharged with ≤ 6 opioid pain pills (5mg oxycodone or equivalent) and do not get a prescription for opioids within 30 days of surgery
High Priority: YES
Linked ICD-10 Codes:
Prostate Cancer: Radical Prostatectomy Cases LOS
Description: Percentage of radical prostatectomy cases with a length of stay > 2 days
High Priority: YES
Linked ICD-10 Codes:
Prostate Cancer: Urinary continence at 12 months post-radical prostatectomy
Description: Percentage of radical prostatectomy patients that are socially continent (0 - 1 pads per day) at 12 months after surgery
High Priority: YES
Linked ICD-10 Codes:
Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
Description: Provide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (e.g., MIPS eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:- Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate with small practices to provide alternate hour office visits and urgent care);- Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers); and/or- Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.
High Priority: NO
Linked ICD-10 Codes:
Provide Clinical-Community Linkages
Description: Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.
High Priority: NO
Linked ICD-10 Codes:
Provide Education Opportunities for New Clinicians
Description: MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.
High Priority: NO
Linked ICD-10 Codes:
Provide Patients Electronic Access to Their Health Information
Description: For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programing Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).
High Priority: NO
Linked ICD-10 Codes:
Provide peer-led support for self-management.
Description: Provide peer-led support for self-management.
High Priority: NO
Linked ICD-10 Codes:
PSH Care Coordination
Description: Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:- Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;- Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;- Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or- Implement processes to ensure effective communications and education of patients’ post-discharge instructions.
High Priority: NO
Linked ICD-10 Codes:
Psoriasis – Improvement in Patient-Reported Itch Severity
Description: The percentage of patients, aged 18 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 2 or more points at a follow up visit.
High Priority: YES
Linked ICD-10 Codes:
Psoriasis: Clinical Response to Systemic Medications
Description: Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.
High Priority: YES
Linked ICD-10 Codes:
Psoriasis: Screening for Psoriatic Arthritis
Description: Percentage of patients with diagnosis of psoriasis who are screened for psoriatic arthritis at each visit.
High Priority: YES
Linked ICD-10 Codes:
Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier
Description: Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and/or rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.
High Priority: NO
Linked ICD-10 Codes:
Public Health Registry Reporting
Description: The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.
High Priority: NO
Linked ICD-10 Codes:
Public Health Registry Reporting Exclusion
Description: Any MIPS eligible clinician who does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician's jurisdiction during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Public Health Registry Reporting for Multiple Registry Engagement
Description: Report as true if, active engagement with more than one Public Health Registry in accordance with PI_PHCDRR_4.
High Priority: NO
Linked ICD-10 Codes:
qPTH >50% Reduction at End of Procedure
Description: The percentage of patients where intra-operative PTH decreased by at least 50% from baseline
High Priority: YES
Linked ICD-10 Codes:
Quality of Life - Physical Health Outcomes
Description: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.
High Priority: YES
Linked ICD-10 Codes:
Quality of Life for Patients with Neurotology Disorders
Description: Percentage of neurotology patients whose most recent Quality of Life scores were maintained or improved during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Quality of Life Outcome for Patients with Neurologic Conditions
Description: Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period.
High Priority: YES
Linked ICD-10 Codes:
Query of the Prescription Drug Monitoring Program (PDMP)
Description: For at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a Prescription Drug Monitoring Program (PDMP) for prescription drug history, except where prohibited and in accordance with applicable law.
High Priority: NO
Linked ICD-10 Codes:
Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease
Description: Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified had appropriate follow-up.
High Priority: NO
Linked ICD-10 Codes:
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Description: Percentage of final reports for patients aged 18 years and older undergoing computed tomography (CT) with documentation that one or more of the following dose reduction techniques were used:• Automated exposure control.• Adjustment of the mA and/or kV according to patient size.• Use of iterative reconstruction technique.
High Priority: NO
Linked ICD-10 Codes:
Radical Prostatectomy Pathology Reporting
Description: Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.
High Priority: NO
Linked ICD-10 Codes:
Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
Description: Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available).
High Priority: YES
Linked ICD-10 Codes:
Radiology: Reminder System for Screening Mammograms
Description: Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.
High Priority: YES
Linked ICD-10 Codes:
Radiology: Stenosis Measurement in Carotid Imaging Reports
Description: Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.
High Priority: NO
Linked ICD-10 Codes:
RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
Description: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed.
High Priority: NO
Linked ICD-10 Codes:
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
Description: Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.
High Priority: YES
Linked ICD-10 Codes:
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
Description: Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) who are discharged to home no later than post-operative day #2.
High Priority: YES
Linked ICD-10 Codes:
Rate of communicating results of an amended report with a major discrepancy to the responsible provider
Description: Rate of communicating to the responsible provider the results of diagnostic reports that were amended due to a major discrepancy.
High Priority: YES
Linked ICD-10 Codes:
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)
Description: Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).
High Priority: YES
Linked ICD-10 Codes:
Rate of notification to clinical provider of a new diagnosis of malignancy
Description: The rate of reporting to a responsible clinical provider from the pathologist when there is a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin) from a pathology specimen
High Priority: YES
Linked ICD-10 Codes:
Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)
Description: Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms (AAA) who do not experience a major complication (discharge to home no later than post-operative day #7).
High Priority: YES
Linked ICD-10 Codes:
Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician
Description: Percentage of patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) and who are undergoing maintenance hemodialysis or peritoneal dialysis in an outpatient dialysis facility and for whom documentation is sent to the dialysis unit or referring physician within two business days of the procedure completion or consultation by an interventional nephrologist, radiologist, or vascular surgeon.
High Priority: YES
Linked ICD-10 Codes:
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
Description: Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.
High Priority: YES
Linked ICD-10 Codes:
Refractive Surgery: Patients with a postoperative correction within + or - 0.5 Diopter (D) of the intended correction
Description: Percentage of patients with an actual spherical equivalent within + or - 0.5 D of the intended correction or SE
High Priority: YES
Linked ICD-10 Codes:
Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days
Description: Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better within 30 days
High Priority: YES
Linked ICD-10 Codes:
Regaining Vision After Cataract Surgery
Description: Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and 20/20 best-corrected distance visual acuity or better OR an improvement in best-corrected distance visual acuity within 30 days following the cataract surgery. Weighted average of performance rates reported.
High Priority: YES
Linked ICD-10 Codes:
Regular Review Practices in Place on Targeted Patient Population Needs
Description: Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.
High Priority: NO
Linked ICD-10 Codes:
Regular training in care coordination
Description: Implementation of regular care coordination training.
High Priority: NO
Linked ICD-10 Codes:
Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
Description: Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
High Priority: NO
Linked ICD-10 Codes:
Related readmission for adrenal related problems
Description: Track all surgery related readmissions within 30 days after index surgery where reason for readmission is any of: 1. Hematoma 2. Adrenal Insufficiency 3. Hypertension 4. Pain 5. Wound Infection 6. Pneumonia 7. Dehydration 8. Respiratory Distress
High Priority: YES
Linked ICD-10 Codes:
Relationship-Centered Communication
Description: In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan.The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.
High Priority: NO
Linked ICD-10 Codes:
Renal Mass: Documentation of the RENAL score for patients with small renal mass diagnoses
Description: Percentage of patients diagnosed with a small renal mass (≤ 7 cm) and have their RENAL score documented in the medical record by the attending physician
High Priority: YES
Linked ICD-10 Codes:
Renal Mass: ED Visit or Readmission within 30 days of partial nephrectomy
Description: Percentage of patients with a small renal mass (≤ 7 cm) who underwent a partial nephrectomy and experienced an ED visit or readmission within 30 days of the procedure
High Priority: YES
Linked ICD-10 Codes:
Renal Mass: ED visit or Readmission within 30 days of radical nephrectomy
Description: Percentage of patients with a small renal mass (≤ 7 cm) who underwent a radical nephrectomy and experienced an ED visit or readmission within 30 days of the procedure
High Priority: YES
Linked ICD-10 Codes:
Renal or Ureteral Stone Surgical Treatment
Description: Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Renal or Ureteral Stone Surgical Treatment episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who receive surgical treatment for renal or ureteral stones during the performance period. The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 90 days prior to the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation
Description: Percentage of patients recommended for repeat screening or surveillance colonoscopy within one year or less due to inadequate/poor bowel preparation quality
High Priority: YES
Linked ICD-10 Codes:
Report Turnaround Time: CT
Description: Mean CT report turnaround time (RTAT)
High Priority: YES
Linked ICD-10 Codes:
Report Turnaround Time: Mammography
Description: Mean mammography report turnaround time (RTAT).
High Priority: YES
Linked ICD-10 Codes:
Report Turnaround Time: MRI
Description: Mean MRI report turnaround time (RTAT)
High Priority: YES
Linked ICD-10 Codes:
Report Turnaround Time: PET
Description: Mean PET report turnaround time (RTAT)
High Priority: YES
Linked ICD-10 Codes:
Report Turnaround Time: Radiography
Description: Mean radiography report turnaround time (RTAT). (Does not include mammography.)
High Priority: YES
Linked ICD-10 Codes:
Report Turnaround Time: Ultrasound (Excluding Breast US)
Description: Mean Ultrasound report turnaround time (RTAT)
High Priority: YES
Linked ICD-10 Codes:
Revascularization for Lower Extremity Chronic Critical Limb Ischemia
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from 30 days prior to the revascularization procedure that triggers the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Review of Pain Status Assessment for Patients with Osteoarthritis
Description: Percentage of patients 18 years of age and older with osteoarthritis who completed baseline and follow-up patient-reported pain status assessment and reviewed the results of this assessment with their care provider.
High Priority: YES
Linked ICD-10 Codes:
Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure
Description: Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative
High Priority: NO
Linked ICD-10 Codes:
RHC, IHS or FQHC quality improvement activities
Description: Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting , and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.
High Priority: NO
Linked ICD-10 Codes:
Rheumatoid Arthritis (RA): Functional Status Assessment
Description: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.
High Priority: NO
Linked ICD-10 Codes:
Rheumatoid Arthritis (RA): Glucocorticoid Management
Description: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.
High Priority: NO
Linked ICD-10 Codes:
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Description: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the measurement year.
High Priority: NO
Linked ICD-10 Codes:
Rheumatoid Arthritis Patients with Low Disease Activity or Remission
Description: The proportion of individuals with RA who have low disease activity or are in remission based on the last recorded disease activity score as assessed using an ACR-preferred tool in the measurement year.
High Priority: YES
Linked ICD-10 Codes:
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
Description: Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.
High Priority: YES
Linked ICD-10 Codes:
Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)
Description: This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.
High Priority: YES
Linked ICD-10 Codes:
Routine Cataract Removal with Intraocular Lens (IOL) Implantation
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries who undergo a procedure for routine cataract removal with IOL implantation during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from 60 days prior to the cataract removal procedure that triggers the episode through 90 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Safe Hydroxychloroquine Dosing
Description: If a patient is using hydroxychloroquine, then the average daily dose should be ≤5 mg/kg
High Priority: YES
Linked ICD-10 Codes:
Safe Opioid Prescribing Practices
Description: Percentage of patients, aged 18 years and older, prescribed opioid medications for longer than six weeks’ duration for whom ALL of the following opioid prescribing best practices are followed: 1. Chemical dependency screening (includes laboratory testing and/or questionnaire) within the immediate 6 months prior to the encounter 2. Co-prescription of naloxone or documented discussion regarding offer of Naloxone co-prescription, if prescription is ≥50 MME/day 3. Non co-prescription of benzodiazepine medications by prescribing pain physician and documentation of a discussion with patient regarding risks of concomitant use of benzodiazepine and opioid medications.
High Priority: YES
Linked ICD-10 Codes:
Screening Abdominal Aortic Aneurysm Reporting with Recommendations
Description: Percentage of patients, aged 50-years-old or older, who have had a screening ultrasound for an abdominal aortic aneurysm with a positive finding of abdominal aortic aneurysm (AAA), that have recognized clinical follow up recommendations documented in the final report and direct communication of findings ≥ 5.5 cm in size made to the ordering provider.
High Priority: YES
Linked ICD-10 Codes:
Screening and monitoring for psychosocial problems among children and youth
Description: Percentage of children from 3 to 17 years of age who are receiving a psychiatric or behavioral health intake visit AND who demonstrated a reliable change in parent-reported problem behaviors 2 to 10 months after initial positive screen for externalizing and internalizing behavior problems.
High Priority: YES
Linked ICD-10 Codes:
Screening Colonoscopy Adenoma Detection Rate
Description: The percentage of patients aged 50 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy
High Priority: YES
Linked ICD-10 Codes:
Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery Calcification Regional Distribution Scoring
Description: Percentage of patients, regardless of age, undergoing Coronary Calcium Scoring who have measurable coronary artery calcification (CAC).
High Priority: NO
Linked ICD-10 Codes:
Screening for Osteoporosis for Women Aged 65-85 Years of Age
Description: Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.
High Priority: NO
Linked ICD-10 Codes:
Screening/Surveillance Colonoscopy
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries who receive a screening/surveillance colonoscopy. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the screening/surveillance colonoscopy procedure that triggers the episode through 14 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Security Risk Analysis
Description: Conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician's risk management process.
High Priority: NO
Linked ICD-10 Codes:
Sentinel Lymph Node (SLN) Biopsies for Patients AJCC T1b-T4 Melanoma
Description: Percentage of patients, aged 18 and older, with a diagnosis of AJCC T1b-T4 cutaneous melanoma who received a SLN biopsy
High Priority: NO
Linked ICD-10 Codes:
Sentinel Lymph Node Biopsy for Invasive Breast Cancer
Description: The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure.
High Priority: NO
Linked ICD-10 Codes:
Sepsis Management: Septic Shock: Lactate Clearance Rate of ≥ 10%
Description: Percentage of emergency department visits for patients aged 18 years and older with septic shock resulting in hospital admission who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of ≥ 10% during the emergency department visit
High Priority: YES
Linked ICD-10 Codes:
Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation
Description: Percentage of emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an order for all the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids
High Priority: NO
Linked ICD-10 Codes:
Sepsis: Hour One bundle
Description: Surviving Sepsis Campaign's Hour One bundle initiation in patients with Sepsis and acute organ dysfunction
High Priority: NO
Linked ICD-10 Codes:
Shared-decision making for post-operative management of discomfort following Rhinoplasty
Description: Percentage of patients aged 15 years and older who had a rhinoplasty procedure who had documentation of a pre-operative shared-decision making strategy for multi-modal post-operative management of discomfort. Definitions: Documentation of discussion of at least two mechanisms of pain management from the following terms or phrases (one term or phrase from each list) will meet the measure: List 1) Non-opioid analgesics: Non-narcotic/Non-opioid, Acetaminophen/Tylenol, Cox-II inhibitor (Celecoxib), Local/Marcaine/Block, Anxiolytic, Tramadol, NSAID/ibuprofen List 2) Non-systemic: Ice/Cooling, Elevation, Rest, Mindfulness, Meditation
High Priority: YES
Linked ICD-10 Codes:
Simple Pneumonia with Hospitalization
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries hospitalized with simple pneumonia during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 30 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Skin Cancer Surgery: Post-Operative Complications
Description: Percentage of patients, regardless of age, with a diagnosis of basal cell carcinoma, squamous cell carcinoma, or melanoma (including in situ disease) with a post-operative complication including infection, bleeding, or hematoma following a scalpel-based surgical procedure or Mohs surgery within 15 days of the procedure.
High Priority: YES
Linked ICD-10 Codes:
Skin Cancer: Biopsy Reporting Time - Clinician to Patient
Description: Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma or melanoma (including in situ disease) or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 14 days from the time the biopsy was performed.
High Priority: YES
Linked ICD-10 Codes:
Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician
Description: Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.
High Priority: YES
Linked ICD-10 Codes:
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
Description: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.
High Priority: NO
Linked ICD-10 Codes:
Sleep Apnea: Severity Assessment at Initial Diagnosis
Description: Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis.
High Priority: NO
Linked ICD-10 Codes:
Sleep Quality Assessment and Sleep Response at 3-months
Description: Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool AND demonstrated a response to treatment at three months (+/- 60 days) after index visit
High Priority: YES
Linked ICD-10 Codes:
Social Role Functioning Outcome utilizing PROMIS
Description: The percentage of adult patients (18 years of age or older) with a mood or anxiety disorder who report concerns related to their psychosocial function and demonstrated a response to treatment six months (+/- 120 days) after the index visit
High Priority: YES
Linked ICD-10 Codes:
Standard BPPV Management
Description: Percentage of BPPV patients who received vestibular testing, imaging, and antihistamine or benzodiazepine medications (Inverse Measure).
High Priority: YES
Linked ICD-10 Codes:
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Description: Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:• Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR• Adults aged ≥ 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL.
High Priority: NO
Linked ICD-10 Codes:
ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)
Description: A clinician's risk-adjusted cost to Medicare for beneficiaries who present with STEMI, indicating complete blockage of a coronary artery, who emergently receive PCI as treatment during the performance period. Includes costs of services that are clinically related to the attributed clinician’s role in managing care from the inpatient hospitalization that triggers the episode through 30 days after the trigger.
High Priority: NO
Linked ICD-10 Codes:
Stones: Inappropriate Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment
Description: Percentage of patients who underwent inappropriate repeat SWL within 6 months of initial procedure
High Priority: YES
Linked ICD-10 Codes:
Stones: Urinalysis Performed Before Surgical Stone Procedures
Description: Percentage of patients with a documented urinalysis 30 days before surgical stone procedures
High Priority: YES
Linked ICD-10 Codes:
Stress echo performance for shortness of breath per ASE guidelines
Description: Stress echo performance for shortness of breath per ASE guidelines on patients 18 years of age or older. This is a multi-strata measure consisting of the following: 1. Percentage of stress echo studies presenting with an indication of unexplained dyspnea that include an interpretation of LV diastolic function parameters with exercise. 2. Percentage of stress echo studies presenting with significant aortic or mitral valve disease that include reporting of value function and regurgitation with exercise. The overall performance will be calculated using a weighted average.
High Priority: YES
Linked ICD-10 Codes:
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Description: Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV alteplase was initiated within three hours of time last known well.
High Priority: NO
Linked ICD-10 Codes:
Structured Walking Program Prior to Intervention for Claudication
Description: Proportion of patients who completed a structured walking program of a duration not less than 12 weeks prior to undergoing peripheral arterial intervention in patients with claudication
High Priority: YES
Linked ICD-10 Codes:
Support Electronic Referral Loops By Receiving and Reconciling Health Information
Description: For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.
High Priority: NO
Linked ICD-10 Codes:
Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
Description: Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Support Electronic Referral Loops By Sending Health Information
Description: For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider - (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.
High Priority: NO
Linked ICD-10 Codes:
Support Electronic Referral Loops By Sending Health Information Exclusion
Description: Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.
High Priority: NO
Linked ICD-10 Codes:
Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD)
Description: Percentage of surgical ptosis patients with an improvement of MRD within 90 days postoperatively.
High Priority: YES
Linked ICD-10 Codes:
Surgical Pediatric Esotropia: Postoperative alignment
Description: Percentage of surgical esotropia pediatric patients with a postoperative alignment of 12 prism diopters (PD) or less without a reoperation.
High Priority: YES
Linked ICD-10 Codes:
Surgical Site Infection (SSI)
Description: Percentage of patients aged 18 years and older who had a surgical site infection (SSI).
High Priority: YES
Linked ICD-10 Codes:
Surgical Site Infection Rate - Mohs Micrographic Surgery
Description: Percentage of cases of Mohs surgery that develop a surgical site infection. This measure is to be reported each time a procedure for a Mohs surgery is performed whether or not a surgical site infection develops during the performance period.
High Priority: YES
Linked ICD-10 Codes:
Surveillance Imaging for Liver Nodules <10mm in Patients at Risk for Hepatocellular Carcinoma (HCC)
Description: Percentage of final ultrasound reports with findings of liver nodules < 10 mm for patients aged 18 years and older with a diagnosis of hepatitis B or cirrhosis undergoing screening and/or surveillance imaging for hepatocellular carcinoma with a specific recommendation for follow-up ultrasound imaging in 3-6 months based on radiological findings
High Priority: YES
Linked ICD-10 Codes:
Symptom Improvement in adults with ADHD
Description: The percentage of adult patients (18 years of age or older) with a diagnosis of ADHD who show a reduction in symptoms of 25% on the Adult ADHD Self-Report Scale (ASRS-v1.1)- 18 item self-report scale of ADHD symptoms within 2 to 10months after initially reporting significant symptoms. There are two aspects to this measure. The first is the assessment of the use of the ASRS v.1. during the denominator identification period (Criteria 1 also referred to as Time 1) and the second is the assessment of improvement in the ASRS v.1.1 from the first administration to the second administration of the ASRS v.1.1 (Criteria 2 also referred to as Time 2).
High Priority: YES
Linked ICD-10 Codes:
Syndromic Surveillance Reporting
Description: The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data from an urgent care setting.
High Priority: NO
Linked ICD-10 Codes:
Syndromic Surveillance Reporting Exclusion
Description: Any MIPS eligible clinician who is not in a category of health care providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system.
High Priority: NO
Linked ICD-10 Codes:
Syndromic Surveillance Reporting for Multiple Registry Engagement
Description: Report as true if, active engagement with more than one Syndromic Surveillance registry in accordance with PI_PHCDRR_2.
High Priority: NO
Linked ICD-10 Codes:
Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients
Description: Percentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for ≥48 hours and who received critical care services who have documentation by managing physician of 1) attempted or actual identification of a surrogate decision maker, 2) an advance directive, and 3) the patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admission
High Priority: YES
Linked ICD-10 Codes:
Tendinitis/ Enthesopathy- Injection Treatment Outcomes for Adults
Description: Percentage of patients aged 18 or older with a diagnosis of Tendinitis that have a reduction in pain after injection therapy
High Priority: YES
Linked ICD-10 Codes:
Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC)
Description: Measurement of the time interval beginning with the time results are verified (clinical) until the critical value is reported by the laboratory for CSF-WBC. (Done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.
High Priority: YES
Linked ICD-10 Codes:
Time interval: critical value reporting for chemistry
Description: Measurement of the time interval beginning with the time results are verified for any of the following Sodium, Potassium, Chloride, Calcium-total, Bicarbonate – CO2, Ammonia, Total Bilirubin – Newborn, Glucose, Glucose – Newborn tests until the critical value is reported by the laboratory. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received, this should be considered as performance not met.
High Priority: YES
Linked ICD-10 Codes:
Time interval: critical value reporting for toxicology
Description: Measurement of the time interval beginning with the time results are verified until the critical value is reported by the laboratory for Carbamazepine, Phenobarbital, and Acetaminophen toxicology tests. (Reporting done via phone, or secure electronic transmission, such as text messaging, messaging through Laboratory Information Systems, Electronic Health Records systems, or email with read receipt functionality). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.
High Priority: YES
Linked ICD-10 Codes:
Time interval: critical value reporting for troponin
Description: Measurement of the time interval beginning with the time results are verified for Troponin (CPT - 84484) until the critical value is reported by the laboratory. (Reporting done via phone, email with read receipt functionality, or text). When notification is sent by email, performance met is contingent on read receipt received. If a read receipt is not received this should be considered as performance not met.
High Priority: YES
Linked ICD-10 Codes:
Tobacco use
Description: Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.
High Priority: NO
Linked ICD-10 Codes:
Tobacco Use and Help with Quitting Among Adolescents
Description: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.
High Priority: NO
Linked ICD-10 Codes:
Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD
Description: Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED and discharged who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user
High Priority: NO
Linked ICD-10 Codes:
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
Description: Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.
High Priority: YES
Linked ICD-10 Codes:
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
Description: Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).
High Priority: YES
Linked ICD-10 Codes:
Total Per Capita Costs (TPCC)
Description: The overall, payment-standardized, annualized, risk-adjusted, and specialty-adjusted cost of care provided to beneficiaries attributed to their primary care clinicians.
High Priority: NO
Linked ICD-10 Codes:
Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.
Description: To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period. Reporting the PRC modifiers enables the identification of a clinician’s relationship with, and responsibility for, a patient at the time of furnishing an item or service. See the CY 2018 PFS final rule (82 FR 53232 through 53234) for more details on these codes.
High Priority: NO
Linked ICD-10 Codes:
Transplant Referral
Description: Percentage of patients aged 18 -75 years old with a diagnosis of end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis for 90 days or longer who are referred to a transplant center for kidney transplant evaluation within a 12-month period.
High Priority: YES
Linked ICD-10 Codes:
Transthoracic Echo (TTE) performance per ASE guidelines
Description: Transthoracic Echo (TTE) performance per ASE guidelines on patients 18 years of age or older. This is a multi-strata measure consisting of the following: 1. Percentage of comprehensive TTE studies reporting 100% obtainment of required views. 2. Percentage of limited and comprehensive TTE studies where the study quality was poor or technically difficult that utilized contrast. 3. Percentage of comprehensive TTE studies reporting pulmonary artery pressures. 4. Percentage of comprehensive TTE studies reporting of diastolic function. 5. Percentage of limited and comprehensive TTE studies reporting cardiac function using strain analysis in patients receiving chemotherapy. The overall performance will be calculated using a weighted average.
High Priority: YES
Linked ICD-10 Codes:
Tuberculosis Screening Prior to First Course Biologic Therapy
Description: If a patient has been newly prescribed a biologic disease-modifying anti-rheumatic drug (DMARD) therapy, then the medical record should indicate TB testing in the preceding 12-month period.
High Priority: NO
Linked ICD-10 Codes:
Tunneled Hemodialysis Catheter Success
Description: Tunneled Hemodialysis Catheter Success is the percentage of patients with ESRD that had insertion or replacement of a central venous access device during the past 12 months who received a full dialysis treatment within 72 hours of catheter insertion or replacement.
High Priority: YES
Linked ICD-10 Codes:
Turnaround Time (TAT) - Biopsies
Description: Percentage of final pathology reports for biopsies that meet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 2 business days). INSTRUCTIONS: This measure is to be reported each time a biopsy is performed during the performance period. It is anticipated that eligible clinicians providing the pathology services for procedures will submit this measure.
High Priority: YES
Linked ICD-10 Codes:
Tympanostomy Tubes: Hearing Test
Description: Percentage of patients age 6 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion and received a hearing test within 6 months prior to tympanostomy tube insertion
High Priority: NO
Linked ICD-10 Codes:
Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Adults and Children
Description: Percentage of patients aged 6 months and older with a diagnosis of otitis media with effusion who are seen 2 to 8 weeks after tympanostomy tube surgery and otitis media with effusion is resolved.
High Priority: YES
Linked ICD-10 Codes:
Tympanostomy Tubes: Topical Ear Drop Monotherapy Acute Otorrhea
Description: Percentage of patients age 6 months to 12 years of age at the time of the visit with a current diagnosis of an uncomplicated acute tympanostomy tube otorrhea (TTO) who were prescribed or recommended to use topical antibiotic eardrops and NOT prescribed systemic (IV or PO) antibiotics for acute tympanostomy tube otorrhea.
High Priority: YES
Linked ICD-10 Codes:
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
Description: Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.
High Priority: NO
Linked ICD-10 Codes:
Ultrasound Guidance for Peripheral Nerve Block with Patient Experience
Description: Percentage of patients, aged 18 years and older, who undergo upper or lower extremity peripheral nerve blockade and for whom ultrasound guidance is used and documented in the medical record and the patient is sent a survey within 30 days and the survey indicates experience with nerve block.
High Priority: YES
Linked ICD-10 Codes:
Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients
Description: Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.
High Priority: NO
Linked ICD-10 Codes:
Unintentional Weight Loss – Risk Assessment and Plan of Care
Description: Percentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by Provider
High Priority: YES
Linked ICD-10 Codes:
Unplanned hospital readmission following spinal fusion surgery.
Description: Calculation of the percent of patients who require unplanned hospital readmission following spine surgical intervention (cervical or lumbar).
High Priority: YES
Linked ICD-10 Codes:
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Description: Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.
High Priority: YES
Linked ICD-10 Codes:
Unplanned Reoperation within the 30 Day Postoperative Period
Description: Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.
High Priority: YES
Linked ICD-10 Codes:
Upper Extremity Edema Improvement
Description: Upper Extremity Edema Improvement is the percentage of procedures for patients with ESRD that present with upper extremity edema and report an improvement within 48 hours after an intervention has been performed.
High Priority: YES
Linked ICD-10 Codes:
Upper Extremity Nerve Blockade in Shoulder Surgery
Description: Percentage of patients who undergo shoulder arthroscopy or shoulder arthroplasty who have an upper extremity nerve blockade performed before or immediately after the procedure.
High Priority: NO
Linked ICD-10 Codes:
Urinary Bladder Biopsy Diagnostic Requirements For Appropriate Patient Management
Description: Percentage of urinary bladder carcinoma pathology reports that include the procedure, histologic tumor grade, histologic type, muscularis propria presence, presence/absence of lymphovascular invasion and extent of tumor invasion. AND meet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date ≤ 2 business days). INSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score: 1. Percent of cases for which all required data elements of the urinary bladder carcinoma pathology report are included. 2. Percent of cases that meet the maximum 2 business day turnaround time. The overall performance score submitted is a weighted average of: (Performance rate 1 x 70%)+(Performance rate 2 x 30%)
High Priority: YES
Linked ICD-10 Codes:
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Description: Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
High Priority: NO
Linked ICD-10 Codes:
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Description: Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
High Priority: YES
Linked ICD-10 Codes:
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
Description: Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.
High Priority: YES
Linked ICD-10 Codes:
Use evidence-based decision aids to support shared decision-making.
Description: Use evidence-based decision aids to support shared decision-making.
High Priority: NO
Linked ICD-10 Codes:
Use group visits for common chronic conditions (e.g., diabetes).
Description: Use group visits for common chronic conditions (e.g., diabetes).
High Priority: NO
Linked ICD-10 Codes:
Use of a “PEG Test” to Manage Patients Receiving Opioids
Description: Percentage of patients in an outpatient setting, aged 18 and older, in whom a stable dose of opioids are prescribed for greater than 6 weeks for pain control, and the results of a “PEG Test” are correctly interpreted and applied to the management of their opioid prescriptions.
High Priority: YES
Linked ICD-10 Codes:
Use of a risk stratification tool in patients with CAP
Description: Documentation of CURB-65 score should guide the admission decision (1 point each for Confusion, BUN>19, Resp rate >30, SBP <90 or DBP<60, Age >=65) for all patients with Community Acquired Pneumonia). PSI/PORT is more complex than CURB-65, and assigns various point values to age, gender, nursing home residence, presence of neoplastic disease, CHF, liver disease, cerebrovascular disease, CKD, altered mental status, hypotension (<90 mmHg), hypothermia or high fever, tachycardia >125, BPM, Acidosis <7.35, BUN>30, hyponatremia <130, Hct <30, pO2<60 mmHg, and pleural effusion.
High Priority: NO
Linked ICD-10 Codes:
Use of ACE-I or ARB and beta blockade in CHF
Description: Ace I or ARBs AND 1 of [3 beta blockers proven to reduce mortality] (bisoprolol, carvedilol, sustained release metoprolol) are recommended in HFrEF and current or prior symptoms of CHF
High Priority: NO
Linked ICD-10 Codes:
Use of Ankle Foot Orthotics to improve patient function
Description: This measures the improvement in function of patient who are prescribed foot and ankle braces for plantar fasciitis, Posterior Tibial Tendon Dysfunction, and ankle sprains
High Priority: YES
Linked ICD-10 Codes:
Use of Anxiety Severity Measure
Description: The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, BAI) during measurement period.
High Priority: NO
Linked ICD-10 Codes:
Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.
Description: Percentage non-contrast CT Head performed for suspected acute stroke whose final reports include an ASPECTS value.
High Priority: NO
Linked ICD-10 Codes:
Use of Breast Cancer Risk Score on Mammography
Description: The percentage of final reports for screening mammograms which include the patient’s estimated numeric risk assessment based on published guidelines, and appropriate recommendations for supplemental screening based on the patient’s estimated risk and documentation of the source of recommendation.
High Priority: YES
Linked ICD-10 Codes:
Use of Capnography for Non-Operating Room Anesthesia
Description: Percentage of patients receiving anesthesia in a non-operating room setting who have end-tidal carbon dioxide (ETCO2) monitored using capnography.
High Priority: YES
Linked ICD-10 Codes:
Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support
Description: In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain[1] via clinical decision support (CDS). For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.
High Priority: NO
Linked ICD-10 Codes:
Use of certified EHR to capture patient reported outcomes
Description: In support of improving patient access, performing additional activities that enable capture of patient reported outcomes (e.g., home blood pressure, blood glucose logs, food diaries, at-risk health factors such as tobacco or alcohol use, etc.) or patient activation measures through use of certified EHR technology, containing this data in a separate queue for clinician recognition and review.
High Priority: NO
Linked ICD-10 Codes:
Use of decision support and standardized treatment protocols
Description: Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.
High Priority: NO
Linked ICD-10 Codes:
Use of Digital Imaging to Monitor and Improve Treatment Outcomes in Chronic Wound Healing
Description: This measure is specifically for CHRONIC wounds. Those are wounds that have been present for an extended period of time and have not demonstrated healing. Percentage of patients presenting with a non-healing (chronic) wound (present for 6 weeks with no or limited response to treatment) who are currently visiting a provider responsible for their wound care, whose provider is using a software-based wound surface area measurement tool, and whose wound healing rate has accelerated since their provider’s adoption of said tool.
High Priority: YES
Linked ICD-10 Codes:
Use of High-Risk Medications in Older Adults
Description: Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.
High Priority: YES
Linked ICD-10 Codes:
Use of Low Dose Cranial CT or MRI Examinations for Patients with Ventricular Shunts
Description: Percentage of patients aged less than 18 years with a ventricular shunt undergoing cranial imaging exams to evaluate for ventricular shunt malfunction undergoing either low dose cranial CT exams or MRI
High Priority: YES
Linked ICD-10 Codes:
Use of Low Dose CT Studies for Adults with Suspicion of Urolithiasis or Nephrolithiasis
Description: Percentage of patients aged 18 years and older with a diagnosis of urolithiasis or nephrolithiasis undergoing CT imaging exams of the abdomen or pelvis to evaluate for urologic stones undergoing only low-dose CT exams of the abdomen or pelvis without intravenous contrast
High Priority: YES
Linked ICD-10 Codes:
Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)
Description: Percentage of patients, regardless of age, that undergo primary total knee arthroplasty for whom neuraxial anesthesia and/or a peripheral nerve block is performed
High Priority: NO
Linked ICD-10 Codes:
Use of Patient Safety Tools
Description: In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.
High Priority: NO
Linked ICD-10 Codes:
Use of QCDR data for ongoing practice assessment and improvements
Description: Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:- Performance of activities that promote use of standard practices, tools and processes for quality improvement (for example, documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups);- Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);- Use of standardized processes for screening for social determinants of health such as food security, employment, and housing;- Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or- Use of QCDR data for quality improvement such as comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcomes.
High Priority: NO
Linked ICD-10 Codes:
Use of QCDR for feedback reports that incorporate population health
Description: Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.
High Priority: NO
Linked ICD-10 Codes:
Use of Quantitative Criteria for Oncologic FDG PET Imaging
Description: Percentage of final reports for all patients, regardless of age, undergoing non-CNS oncologic FDG PET studies that include at a minimum: a. Serum glucose (e.g., finger stick at time of injection) b. Uptake time (interval from injection to initiation of imaging) c. One reference background (e.g., volumetric normal liver or mediastinal blood pool) SUV measurement, along with description of the SUV measurement type (e.g., SUVmax) and normalization method (e.g., BMI) d. At least one lesional SUV measurement OR diagnosis of "no disease-specific abnormal uptake"
High Priority: YES
Linked ICD-10 Codes:
Use of Structured Reporting in Prostate MRI
Description: Percentage of final reports for male patients aged 18 years and older undergoing prostate MRI for prostate cancer screening or surveillance that include reference to a validated scoring system such as Prostate Imaging Reporting and Data System (PI-RADS)
High Priority: YES
Linked ICD-10 Codes:
Use of telehealth services that expand practice access
Description: Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.
High Priority: NO
Linked ICD-10 Codes:
Use of Thyroid Imaging Reporting & Data System (TI-RADS) in Final Report to Stratify Thyroid Nodule Risk
Description: Percentage of patients, regardless of age, undergoing ultrasound of the neck with findings of thyroid nodule(s) whose reports include the TI-RADS assessment.
High Priority: YES
Linked ICD-10 Codes:
Use of tools to assist patient self-management
Description: Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How’s My Health).
High Priority: NO
Linked ICD-10 Codes:
Use of toolsets or other resources to close healthcare disparities across communities
Description: Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.
High Priority: NO
Linked ICD-10 Codes:
Use of ultrasound guidance for vascular access
Description: Proportion of vascular access using ultrasound guidance for vessel puncture during endovascular procedures.
High Priority: YES
Linked ICD-10 Codes:
Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries
Description: The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.
High Priority: YES
Linked ICD-10 Codes:
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
Description: Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.
High Priority: YES
Linked ICD-10 Codes:
Venous Leg Ulcer (VLU) outcome measure: Healing or Closure
Description: Percentage of venous leg ulcers among patients age 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.
High Priority: YES
Linked ICD-10 Codes:
Venous Thromboembolism (VTE) Prophylaxis
Description: Percentage of Adult Patients Who Had VTE Prophylaxis Ordered at the Time of Admission OR Have Documentation of Reason for No VTE Prophylaxis
High Priority: YES
Linked ICD-10 Codes:
Ventral Hernia Repair: Pain and Functional Status Assessment
Description: Percentage of patients aged 18 years and older who have undergone ventral hernia repair and who completed baseline and 30 day follow-up patient-reported functional status assessments, and achieved at least a 10% improvement in functional status score from baseline.
High Priority: YES
Linked ICD-10 Codes:
Visits to the ER or Urgent Care Following Reconstruction After Skin Cancer Resection
Description: Part 1: Percentage of patients aged 18 and older who underwent reconstruction after skin cancer resection who were asked* within 30 days of their procedure whether they visited the ER or Urgent Care within 7 days of their procedure, for a reason related to the reconstruction after skin cancer resection surgery. Part 2: Percentage of patients, aged 18 and older who underwent reconstruction after skin cancer resection and were asked within 30 days of the procedure about visiting the ER, who visited the ER or Urgent Care within 7 days of their procedure for a reason related to the reconstruction after skin cancer resection surgery. (only Part 2 is intended to be reported for accountability, but Part 1 must be completed)
High Priority: YES
Linked ICD-10 Codes:
Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery
Description: Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and minimally invasive glaucoma surgery and achieved 20/30 best-corrected distance visual acuity or better OR an improvement in best-corrected distance visual acuity within 4 months following the cataract surgery. Weighted average of performance rates reported.
High Priority: YES
Linked ICD-10 Codes:
Visual Acuity Improvement Following Cataract Surgery Combined with a Trabeculectomy or an Aqueous Shunt Procedure
Description: Percentage of eyes of patients who underwent cataract surgery combined with a trabeculectomy or an aqueous shunt procedure who had their visual acuity improve 1 or 2 or more Snellen lines from their preoperative visual acuity between 3 and 6 months postoperatively. Weighted average of performance rates reported.
High Priority: YES
Linked ICD-10 Codes:
Visual Field Progression in Glaucoma
Description: Percentage of patients with a diagnosis of glaucoma with a mean deviation loss of 3dB or more from their baseline value.
High Priority: YES
Linked ICD-10 Codes:
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Description: Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.• Percentage of patients with height, weight, and body mass index (BMI) percentile documentation.• Percentage of patients with counseling for nutrition.• Percentage of patients with counseling for physical activity.
High Priority: NO
Linked ICD-10 Codes: