With MedServiz- don’t just tackle Macra but Capitilize on it!
Experts at MedServiz will guide you on “which is the Right System for you- MIPS or APM ?”
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0654
- Quality ID : 093
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Emergency Medicine
- Otolaryngology
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Acute Otitis Externa (AOE): Topical Therapy
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0653
- Quality ID : 091
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Emergency Medicine
- Otolaryngology
- Pediatrics
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
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.
Measure Number
- eMEASURE ID : CMS136v6
- eMeasure NQF : None
- NQF : 0108
- Quality ID : 366
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Mental/Behavioral Health
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Adherence to Antipsychotic Medications For Individuals with Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the measurement 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 measurement period (12 consecutive months)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1879
- Quality ID : 383
NQS Domain
PS
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Mental/Behavioral Health
Primary Measure Steward
Health Services Advisory Group
Adult Kidney Disease: Blood Pressure Management
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 122
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Renal Physicians Association
Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 329
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Renal Physicians Association
Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 330
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Renal Physicians Association
Adult Kidney Disease: Referral to Hospice
Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 403
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Renal Physicians Association
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 325
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Mental/Behavioral Health
Primary Measure Steward
American Psychiatric Association
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
Measure Number
- eMEASURE ID : CMS161v5
- eMeasure NQF : None
- NQF : 0104
- Quality ID : 107
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
Physician Consortium for Performance Improvement
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 384
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 385
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 331
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 332
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 333
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 334
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Age Appropriate Screening Colonoscopy
The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 439
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0566
- Quality ID : 140
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
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 hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0087
- Quality ID : 014
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
All-cause Hospital Readmission
The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1789
- Quality ID : 458
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
No
Data Submission Method
- Administrative Claims
Speciality Measure Set
Primary Measure Steward
Yale University
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 386
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Anastomotic Leak Intervention
Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 354
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Surgery
Primary Measure Steward
American College of Surgeons
Anesthesiology Smoking Abstinence
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 404
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 387
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Anti-Depressant Medication Management
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).
Measure Number
- eMEASURE ID : CMS128v5
- eMeasure NQF : None
- NQF : 0105
- Quality ID : 009
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Internal Medicine
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 421
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Interventional Radiology
Appropriate Follow-up Imaging for Incidental Abdominal Lesions
Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended:
- Liver lesion <= 0.5 cm
- Cystic kidney lesion < 1.0 cm
- Adrenal lesion <= 1.0 cm
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 405
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
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 or ultrasound of the 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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 406
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0658
- Quality ID : 320
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Appropriate Testing for Children with Pharyngitis
Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode
Measure Number
- eMEASURE ID : CMS146v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 066
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Emergency Medicine
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode
Measure Number
- eMEASURE ID : CMS154v5
- eMeasure NQF : None
- NQF : 0069
- Quality ID : 065
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia
Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 407
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Hospitalists
Primary Measure Steward
Infectious Diseases Society of America
Appropriate Workup Prior to Endometrial Ablation
Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy before undergoing an endometrial ablation
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0567
- Quality ID : 448
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1525
- Quality ID : 326
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
American College of Cardiology
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0058
- Quality ID : 116
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- Emergency Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Barrett’s Esophagus
Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1854
- Quality ID : 249
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician
Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 440
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Academy of Dermatology
Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 265
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Dermatology
- Interventional Radiology
- Obstetrics/Gynecology
- Urology
Primary Measure Steward
American Academy of Dermatology
Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use
Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use
Measure Number
- eMEASURE ID : CMS169v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 367
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
Center for Quality Assessment and Improvement in Mental Health
Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0391
- Quality ID : 099
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Breast Cancer Screening
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.
Measure Number
- eMEASURE ID : CMS125v5
- eMeasure NQF : None
- NQF : 2372
- Quality ID : 112
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
CAHPS for MIPS Clinician/Group Survey
- Getting timely care, appointments, and information;
- How well providers Communicate;
- Patient's Rating of Provider;
- Access to Specialists;
- Health Promotion & Education;
- Shared Decision Making;
- Health Status/Functional Status;
- Courteous and Helpful Office Staff;
- Care Coordination;
- Between Visit Communication;
- Helping Your to Take Medication as Directed; and
- Stewardship of Patient Resources
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0006 & 0005
- Quality ID : 321
NQS Domain
PCCEO
Measure Type
Patient Engagement Experience
High Priority Measure
Yes
Data Submission Method
- CSV
Speciality Measure Set
- General Practice/Family Medicine
Primary Measure Steward
Agency for Healthcare Research & Quality
Cardiac Rehabilitation Patient Referral from an Outpatient Setting
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0643
- Quality ID : 243
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American College of Cardiology Foundation
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients
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 reporting period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 322
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Cardiology
Primary Measure Steward
American College of Cardiology
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 323
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Cardiology
Primary Measure Steward
American College of Cardiology
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 324
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Cardiology
Primary Measure Steward
American College of Cardiology
Care Plan
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0326
- Quality ID : 047
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- Cardiology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)
Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 388
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cataract Surgery: Difference Between Planned and Final Refraction
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 389
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery 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 within 90 days following the cataract surgery
Measure Number
- eMEASURE ID : CMS133v5
- eMeasure NQF : None
- NQF : 0565
- Quality ID : 191
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence
Measure Number
- eMEASURE ID : CMS132v5
- eMeasure NQF : None
- NQF : 0564
- Quality ID : 192
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1536
- Quality ID : 303
NQS Domain
PCCEO
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 304
NQS Domain
PCCEO
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Cervical Cancer Screening
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 every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Measure Number
- eMEASURE ID : CMS124v5
- eMeasure NQF : None
- NQF : 0032
- Quality ID : 309
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Obstetrics/Gynecology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
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
Measure Number
- eMEASURE ID : CMS177v5
- eMeasure NQF : None
- NQF : 1365
- Quality ID : 382
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Mental/Behavioral Health
- Pediatrics
Primary Measure Steward
Physician Consortium for Performance Improvement
Childhood Immunization Status
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 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
Measure Number
- eMEASURE ID : CMS117v5
- eMeasure NQF : None
- NQF : 0038
- Quality ID : 240
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Children Who Have Dental Decay or Cavities
Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period
Measure Number
- eMEASURE ID : CMS75v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 378
NQS Domain
CPH
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
Centers for Medicare & Medicaid Services
Chlamydia Screening and Follow Up
The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 447
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
National Committee for Quality Assurance
Chlamydia Screening for Women
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
Measure Number
- eMEASURE ID : CMS153v5
- eMeasure NQF : None
- NQF : 0033
- Quality ID : 310
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Obstetrics/Gynecology
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy
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 an long-acting inhaled bronchodilator
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0102
- Quality ID : 052
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
American Thoracic Society
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0091
- Quality ID : 051
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
American Thoracic Society
Clinical Outcome Post Endovascular Stroke Treatment
Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 409
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Interventional Radiology
Closing the Referral Loop: Receipt of Specialist Report
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
Measure Number
- eMEASURE ID : CMS50v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 374
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Allergy/Immunology
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0659
- Quality ID : 185
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0392
- Quality ID : 100
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Colorectal Cancer Screening
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
Measure Number
- eMEASURE ID : CMS130v5
- eMeasure NQF : None
- NQF : 0034
- Quality ID : 113
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older
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 reported by the physician who treats the fracture and who therefore is held accountable for the communication
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0045
- Quality ID : 024
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Preventive Medicine
Primary Measure Steward
National Committee for Quality Assurance
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Measure Number
- eMEASURE ID : CMS165v5
- eMeasure NQF : None
- NQF : 0018
- Quality ID : 236
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Internal Medicine
- Cardiology
- Obstetrics/Gynecology
- Preventive Medicine
- Thoracic Surgery
- Vascular Surgery
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0130
- Quality ID : 165
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0114
- Quality ID : 167
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0236
- Quality ID : 044
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Anesthesiology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0129
- Quality ID : 164
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Stroke
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0131
- Quality ID : 166
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0115
- Quality ID : 168
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0134
- Quality ID : 043
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Thoracic Surgeons
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0066
- Quality ID : 118
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Cardiology
Primary Measure Steward
American Heart Association
Coronary Artery Disease (CAD): Antiplatelet Therapy
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0067
- Quality ID : 006
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Cardiology
Primary Measure Steward
American Heart Association
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
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
Measure Number
- eMEASURE ID : CMS145v5
- eMeasure NQF : None
- NQF : 0070
- Quality ID : 007
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Dementia: Caregiver Education and Support
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 288
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Dementia: Cognitive Assessment
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
Measure Number
- eMEASURE ID : CMS149v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 281
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
Physician Consortium for Performance Improvement
Dementia: Counseling Regarding Safety Concerns
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 286
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Dementia: Functional Status Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 282
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Dementia: Management of Neuropsychiatric Symptoms
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 284
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Dementia: Neuropsychiatric Symptom Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 283
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Depression Remission at Six Months
Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0711
- Quality ID : 411
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Mental/Behavioral Health
Primary Measure Steward
Minnesota Community Measurement
Depression Remission at Twelve Months
Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
Measure Number
- eMEASURE ID : CMS159v5
- eMeasure NQF : None
- NQF : 0710
- Quality ID : 370
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
- CMS Web Interface
Speciality Measure Set
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
Minnesota Community Measurement
Depression Utilization of the PHQ-9 Tool
Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit
Measure Number
- eMEASURE ID : CMS160v5
- eMeasure NQF : None
- NQF : 0712
- Quality ID : 371
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Mental/Behavioral Health
Primary Measure Steward
Minnesota Community Measurement
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0417
- Quality ID : 126
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Podiatric Medical Association
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0416
- Quality ID : 127
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Podiatric Medical Association
Diabetes: Eye Exam
Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period
Measure Number
- eMEASURE ID : CMS131v5
- eMeasure NQF : None
- NQF : 0055
- Quality ID : 117
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- CMS Web Interface
- EHR
Speciality Measure Set
- Internal Medicine
- Ophthalmology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Diabetes: Foot Exam
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year
Measure Number
- eMEASURE ID : CMS123v5
- eMeasure NQF : None
- NQF : 0056
- Quality ID : 163
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Measure Number
- eMEASURE ID : CMS122v5
- eMeasure NQF : None
- NQF : 0059
- Quality ID : 001
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- CMS Web Interface
- EHR
Speciality Measure Set
- Internal Medicine
- Preventive Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Diabetes: Medical Attention for Nephropathy
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.
Measure Number
- eMEASURE ID : CMS134v5
- eMeasure NQF : None
- NQF : 0062
- Quality ID : 119
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
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
Measure Number
- eMEASURE ID : CMS142v5
- eMeasure NQF : None
- NQF : 0089
- Quality ID : 019
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- EHR
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months
Measure Number
- eMEASURE ID : CMS167v5
- eMeasure NQF : None
- NQF : 0088
- Quality ID : 018
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
Measure Number
- eMEASURE ID : CMS68v6
- eMeasure NQF : None
- NQF : 0419
- Quality ID : 130
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- EHR
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Anesthesiology
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 412
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- Neurology
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Neurology
Door to Puncture Time for Endovascular Stroke Treatment
Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 413
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Interventional Radiology
Elder Maltreatment Screen and Follow-Up Plan
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 181
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 415
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and 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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 416
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1814
- Quality ID : 268
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 414
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- Neurology
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Neurology
Falls: Plan of Care
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0101
- Quality ID : 155
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0101
- Quality ID : 154
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Falls: Screening for Future Fall Risk
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
Measure Number
- eMEASURE ID : CMS139v5
- eMeasure NQF : None
- NQF : 0101
- Quality ID : 318
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
- CMS Web Interface
Speciality Measure Set
Primary Measure Steward
National Committee for Quality Assurance
Follow-Up After Hospitalization for Mental Illness (FUH)
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:
- The percentage of discharges for which the patient received follow-up within 30 days of discharge.
- The percentage of discharges for which the patient received follow-up within 7 days of discharge
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0576
- Quality ID : 391
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Mental/Behavioral Health
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Functional Outcome Assessment
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2624
- Quality ID : 182
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Physical Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Assessment for Total Hip Replacement
Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments
Measure Number
- eMEASURE ID : CMS56v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 376
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Orthopedic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Assessment for Total Knee Replacement
Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments
Measure Number
- eMEASURE ID : CMS66v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 375
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Orthopedic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Assessments for Congestive Heart Failure
Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Measure Number
- eMEASURE ID : CMS90v6
- eMeasure NQF : None
- NQF : None
- Quality ID : 377
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
Centers for Medicare & Medicaid Services
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes 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, and at the clinic level to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0427
- Quality ID : 222
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Foot or Ankle Impairments
A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes 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, and at the clinic level to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0424
- Quality ID : 219
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with General Orthopaedic Impairments
A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes 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, and at the clinic level by to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0428
- Quality ID : 223
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Hip Impairments
A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes 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, and at the clinic level to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0423
- Quality ID : 218
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Knee Impairments
A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes 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, and at the clinic level to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0422
- Quality ID : 217
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Lumbar Impairments
A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome 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, and at the clinic level by to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0425
- Quality ID : 220
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Functional Status Change for Patients with Shoulder Impairments
A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes 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, and at the clinic level to assess quality
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0426
- Quality ID : 221
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
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 therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Measure Number
- eMEASURE ID : CMS135v5
- eMeasure NQF : 2907
- NQF : 0081
- Quality ID : 005
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Internal Medicine
- Cardiology
- Hospitalists
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
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
Measure Number
- eMEASURE ID : CMS144v5
- eMeasure NQF : 2908
- NQF : 0083
- Quality ID : 008
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Cardiology
- Hospitalists
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0379
- Quality ID : 070
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Physician Consortium for Performance Improvement
Hematology: Multiple Myeloma: Treatment with Bisphosphonates
Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0380
- Quality ID : 069
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Society of Hematology
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0377
- Quality ID : 067
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Society of Hematology
Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy
Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0378
- Quality ID : 068
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Society of Hematology
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 390
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
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 reporting period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 401
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- Gastroenterology
- General Practice/Family Medicine
Primary Measure Steward
American Gastroenterological Association
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies
Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1857
- Quality ID : 449
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
HIV Medical Visit Frequency
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2079
- Quality ID : 340
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Health Resources and Services Administration
HIV Viral Load Suppression
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2082
- Quality ID : 338
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Practice/Family Medicine
Primary Measure Steward
Health Resources and Services Administration
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis
Measure Number
- eMEASURE ID : CMS52v5
- eMeasure NQF : None
- NQF : 0405
- Quality ID : 160
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Allergy/Immunology
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0409
- Quality ID : 205
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender:
- Reporting Age Criteria 1: Females 18-64years of age
- Reporting Age Criteria 2: Males 18-64 years of age
- Reporting Age Criteria 3: Females 65 years of age and older
- Reporting Age Criteria 4: Males 65 years of age and older
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2474
- Quality ID : 392
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate
Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 348
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
Infection rate following CIED device implantation, replacement, or revision
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 393
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
Hypertension: Improvement in Blood Pressure
Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
Measure Number
- eMEASURE ID : CMS65v6
- eMeasure NQF : None
- NQF : None
- Quality ID : 373
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
Centers for Medicare & Medicaid Services
Image Confirmation of Successful Excision of Image-Localized Breast Lesion
Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 262
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Society of Breast Surgeons
Immunizations for Adolescents
The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1407
- Quality ID : 394
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 275
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment
Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 271
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
Measure Number
- eMEASURE ID : CMS137v5
- eMeasure NQF : None
- NQF : 0004
- Quality ID : 305
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
National Committee for Quality Assurance
Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
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 140/90 mm Hg -- And
- Most recent tobacco status is Tobacco Free -- And
- Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And
- Statin Use
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 441
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Wisconsin Collaborative for Healthcare Quality
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.
Measure Number
- eMEASURE ID : CMS164v5
- eMeasure NQF : None
- NQF : 0068
- Quality ID : 204
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Internal Medicine
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1859
- Quality ID : 451
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Lung Cancer Reporting (Biopsy/Cytology Specimens)
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 NSCLC-NOS with an explanation included in the pathology report
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 395
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Lung Cancer Reporting (Resection Specimens)
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, histologic type
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 396
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Maternal Depression Screening
The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.
Measure Number
- eMEASURE ID : CMS82v4
- eMeasure NQF : None
- NQF : None
- Quality ID : 372
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
National Committee for Quality Assurance
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)
Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at >= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 335
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Centers for Medicare & Medicaid Services
Maternity Care: Post-Partum Follow-Up and Care Coordination
Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 336
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Centers for Medicare & Medicaid Services
Medication Management for People with Asthma
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1799
- Quality ID : 444
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Medication Reconciliation Post-Discharge
The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.
This measure is reported as three rates stratified by age group:
- Reporting Criteria 1: 18-64 years of age
- Reporting Criteria 2: 65 years and older
- Total Rate: All patients 18 years of age and older
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0097
- Quality ID : 046
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- CMS Web Interface
- Registry
Speciality Measure Set
Primary Measure Steward
National Committee for Quality Assurance
Melanoma Reporting
Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 397
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Melanoma: Continuity of Care – Recall System
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0650
- Quality ID : 137
NQS Domain
CCC
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Melanoma: Coordination of Care
Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 138
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Melanoma: Overutilization of Imaging Studies in Melanoma
Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0562
- Quality ID : 224
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 443
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
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, MRI, CT, etc.) that were performed
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 147
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
Society of Nuclear Medicine and Molecular Imaging
Oncology: Medical and Radiation – Pain Intensity Quantified
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
Measure Number
- eMEASURE ID : CMS157v5
- eMeasure NQF : None
- NQF : 0384
- Quality ID : 143
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- General Oncology
- Radiation Oncology
Primary Measure Steward
Physician Consortium for Performance Improvement
Oncology: Medical and Radiation – Plan of Care for Pain
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0383
- Quality ID : 144
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Radiation Oncology
Primary Measure Steward
American Society of Clinical Oncology
Oncology: Radiation Dose Limits to Normal Tissues
Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0382
- Quality ID : 156
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Radiation Oncology
Primary Measure Steward
American Society for Radiation Oncology
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 400
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories
Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0733
- Quality ID : 446
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Thoracic Surgeons
Opioid Therapy Follow-up Evaluation
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 408
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- Neurology
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Neurology
Optimal Asthma Control
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 398
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- General Practice/Family Medicine
Primary Measure Steward
Minnesota Community Measurement
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 364
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 362
NQS Domain
CCC
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 360
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 361
NQS Domain
PS
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive
Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 363
NQS Domain
CCC
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description
Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution's computer systems
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 359
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 109
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- Orthopedic Surgery
- Physical Medicine
- Preventive Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Orthopedic Surgeons
Osteoporosis Management in Women Who Had a Fracture
The percentage of women age 50-85 who suffered a fracture 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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0053
- Quality ID : 418
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- Obstetrics/Gynecology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination
Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 419
NQS Domain
ECR
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Pain Assessment and Follow-Up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0420
- Quality ID : 131
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Physical Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Pain Brought Under Control Within 48 Hours
Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 342
NQS Domain
PCCEO
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Practice/Family Medicine
Primary Measure Steward
National Hospice and Palliative Care Organization
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
All patients with a diagnosis of Parkinson's disease who were assessed for cognitive impairment or dysfunction in the last 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 291
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
All patients with a diagnosis of Parkinson's disease (or caregiver(s), as appropriate) who had the Parkinson's disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least annually
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 294
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease
All patients with a diagnosis of Parkinson's disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 290
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Parkinson’s Disease: Rehabilitative Therapy Options
All patients with a diagnosis of Parkinson's Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 293
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Patient-Centered Surgical Risk Assessment and Communication
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 358
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Surgery
- Orthopedic Surgery
- Otolaryngology
- Thoracic Surgery
- Urology
- Plastic Surgery
Primary Measure Steward
American College of Surgeons
Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1860
- Quality ID : 452
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Pediatric Kidney Disease: Adequacy of Volume Management
Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 327
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Renal Physicians Association
Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL
Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1667
- Quality ID : 328
NQS Domain
ECC
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Renal Physicians Association
Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence
Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 428
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Urogynecologic Society
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy
Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 429
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
American Urogynecologic Society
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2063
- Quality ID : 422
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
American Urogynecologic Society
Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy
Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0465
- Quality ID : 423
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
Society for Vascular Surgeons
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0268
- Quality ID : 021
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- General Surgery
- Orthopedic Surgery
- Otolaryngology
- Thoracic Surgery
- Plastic Surgery
Primary Measure Steward
American Society of Plastic Surgeons
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0239
- Quality ID : 023
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- General Surgery
- Orthopedic Surgery
- Otolaryngology
- Thoracic Surgery
- Plastic Surgery
Primary Measure Steward
American Society of Plastic Surgeons
Perioperative Temperature Management
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 recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2671
- Quality ID : 424
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Persistence of Beta-Blocker Treatment After a Heart Attack
The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0071
- Quality ID : 442
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Photodocumentation of Cecal Intubation
The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 425
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
American Society for Gastrointestinal Endoscopy
Pneumococcal Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
Measure Number
- eMEASURE ID : CMS127v5
- eMeasure NQF : None
- NQF : 0043
- Quality ID : 111
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Allergy/Immunology
- Preventive Medicine
Primary Measure Steward
National Committee for Quality Assurance
Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)
Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 426
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 427
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Pregnant women that had HBsAg testing
This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy
Measure Number
- eMEASURE ID : CMS158v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 369
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
OptumInsight
Preoperative Diagnosis of Breast Cancer
The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 263
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Society of Breast Surgeons
Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 076
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Anesthesiology
- Hospitalists
Primary Measure Steward
American Society of Anesthesiologists
Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
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 or intraoperatively
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 430
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
Measure Number
- eMEASURE ID : CMS69v5
- eMeasure NQF : None
- NQF : 0421
- Quality ID : 128
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Internal Medicine
- Cardiology
- Gastroenterology
- General Surgery
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Preventive Care and Screening: Influenza Immunization
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
Measure Number
- eMEASURE ID : CMS147v6
- eMeasure NQF : None
- NQF : 0041
- Quality ID : 110
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
Physician Consortium for Performance Improvement
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on 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 positive screen
Measure Number
- eMEASURE ID : CMS2v6
- eMeasure NQF : None
- NQF : 0418
- Quality ID : 134
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Internal Medicine
- Mental/Behavioral Health
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
Centers for Medicare & Medicaid Services
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated
Measure Number
- eMEASURE ID : CMS22v5
- eMeasure NQF : None
- NQF : None
- Quality ID : 317
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Anesthesiology
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user
Measure Number
- eMEASURE ID : CMS138v5
- eMeasure NQF : None
- NQF : 0028
- Quality ID : 226
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
- CMS Web Interface
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
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 24 months AND who received brief counseling if identified as an unhealthy alcohol user
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 2152
- Quality ID : 431
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Internal Medicine
- Cardiology
- Emergency Medicine
- Gastroenterology
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.
Measure Number
- eMEASURE ID : CMS74v6
- eMeasure NQF : None
- NQF : None
- Quality ID : 379
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Speciality Measure Set
- Pediatrics
Primary Measure Steward
Centers for Medicare & Medicaid Services
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
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
Measure Number
- eMEASURE ID : CMS143v5
- eMeasure NQF : None
- NQF : 0086
- Quality ID : 012
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- EHR
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
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 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0563
- Quality ID : 141
NQS Domain
CCC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Proportion Admitted to Hospice for less than 3 days
Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0216
- Quality ID : 457
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life
Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0213
- Quality ID : 455
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Proportion Not Admitted To Hospice
Proportion of patients who died from cancer not admitted to hospice
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0215
- Quality ID : 456
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 432
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
American Urogynecologic Society
Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair
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 1 month after surgery
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 433
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
American Urogynecologic Society
Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 434
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
American Urogynecologic Society
Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life
Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0211
- Quality ID : 454
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Proportion Receiving Chemotherapy in the Last 14 Days of Life
Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0210
- Quality ID : 453
NQS Domain
ECC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer
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 adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0390
- Quality ID : 104
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Urology
Primary Measure Steward
American Urological Association Education and Research
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
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, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
Measure Number
- eMEASURE ID : CMS129v6
- eMeasure NQF : None
- NQF : 0389
- Quality ID : 102
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- General Oncology
- Radiation Oncology
- Urology
Primary Measure Steward
Physician Consortium for Performance Improvement
Psoriasis: Clinical Response to Oral Systemic or Biologic Medications
Percentage of psoriasis patients receiving oral systemic or biologic therapy 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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 410
NQS Domain
PCCEO
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Quality of Life Assessment For Patients With Primary Headache Disorders
Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 435
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients
This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1855
- Quality ID : 251
NQS Domain
ECC
Measure Type
Structure
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Percentage of final reports for patients aged 18 years and older undergoing 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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 436
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Radical Prostatectomy Pathology Reporting
Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1853
- Quality ID : 250
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- General Oncology
- Pathology
Primary Measure Steward
College of American Pathologists
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy
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)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 145
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms
Percentage of final reports for screening mammograms that are classified as "probably benign"
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0508
- Quality ID : 146
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Radiology: Reminder System for Screening Mammograms
Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0509
- Quality ID : 225
NQS Domain
CCC
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Radiology: Stenosis Measurement in Carotid Imaging Reports
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0507
- Quality ID : 195
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 344
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Interventional Radiology
- Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 260
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital
Percent of patients undergoing endovascular repair of small or moderate infrarenal abdominal aortic aneurysms (AAA) that die while in the hospital
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1534
- Quality ID : 347
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
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)
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)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 259
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Interventional Radiology
- Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive
Percentage of patients undergoing open repair of small or moderate abdominal aortic aneurysms (AAA) who are discharged alive
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1523
- Quality ID : 417
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society for Vascular Surgeons
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)
Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 258
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1543
- Quality ID : 345
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Interventional Radiology
- Vascular Surgery
Primary Measure Steward
Society for Vascular Surgeons
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA)
Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1540
- Quality ID : 346
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society for Vascular Surgeons
Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure
Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 437
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Interventional Radiology
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 261
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
Primary Measure Steward
Audiology Quality Consortium
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 255
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 179
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
- Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Functional Status Assessment
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 178
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
- Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Glucocorticoid Management
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 >= 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 180
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
- Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 177
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Rheumatology
Primary Measure Steward
American College of Rheumatology
Rheumatoid Arthritis (RA): Tuberculosis Screening
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 176
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Rheumatology
Primary Measure Steward
American College of Rheumatology
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0119
- Quality ID : 445
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Thoracic Surgeons
Screening Colonoscopy Adenoma Detection Rate
The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 343
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Gastroenterology
Primary Measure Steward
American Society for Gastrointestinal Endoscopy
Screening for Osteoporosis for Women Aged 65-85 Years of Age
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0046
- Quality ID : 039
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Preventive Medicine
Primary Measure Steward
National Committee for Quality Assurance
Sentinel Lymph Node Biopsy for Invasive Breast Cancer
The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 264
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Society of Breast Surgeons
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 279
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Academy of Sleep Medicine
Sleep Apnea: Assessment of Sleep Symptoms
Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 276
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Academy of Sleep Medicine
Sleep Apnea: Positive Airway Pressure Therapy Prescribed
Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 278
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Academy of Sleep Medicine
Sleep Apnea: Severity Assessment at Initial Diagnosis
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 277
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Academy of Sleep Medicine
Statin Therapy at Discharge after Lower Extremity Bypass (LEB)
Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1519
- Quality ID : 257
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society for Vascular Surgeons
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 438
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- CMS Web Interface
- Registry
Speciality Measure Set
- Internal Medicine
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed antithrombotic therapy at discharge
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 032
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Hospitalists
- Neurology
Primary Measure Steward
American Academy of Neurology
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
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 t-PA was initiated within three hours of time last known well
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 187
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
American Heart Association
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 357
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Surgery
- Otolaryngology
- Vascular Surgery
- Plastic Surgery
Primary Measure Steward
American College of Surgeons
Tobacco Use and Help with Quitting Among Adolescents
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 402
NQS Domain
CPH
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Allergy/Immunology
- Internal Medicine
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 353
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 352
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 350
NQS Domain
CCC
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
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)
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 351
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- Orthopedic Surgery
Primary Measure Steward
American Association of Hip and Knee Surgeons
Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy
Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) - III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 1858
- Quality ID : 450
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly 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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 337
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
- Dermatology
- Rheumatology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Dermatology
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : 0651
- Quality ID : 254
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 356
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Surgery
Primary Measure Steward
American College of Surgeons
Unplanned Reoperation within the 30 Day Postoperative Period
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 355
NQS Domain
PS
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Speciality Measure Set
- General Surgery
Primary Measure Steward
American College of Surgeons
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 048
NQS Domain
ECC
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Obstetrics/Gynecology
- Preventive Medicine
- Urology
Primary Measure Steward
National Committee for Quality Assurance
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 050
NQS Domain
PCCEO
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Speciality Measure Set
- Internal Medicine
- Obstetrics/Gynecology
- Urology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Use of High-Risk Medications in the Elderly
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.
Measure Number
- eMEASURE ID : CMS156v5
- eMeasure NQF : None
- NQF : 0022
- Quality ID : 238
NQS Domain
PS
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
Primary Measure Steward
National Committee for Quality Assurance
Use of Imaging Studies for Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Measure Number
- eMEASURE ID : CMS166v6
- eMeasure NQF : None
- NQF : 0052
- Quality ID : 312
NQS Domain
ECR
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Speciality Measure Set
- Orthopedic Surgery
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey
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
Measure Number
- eMEASURE ID : None
- eMeasure NQF : None
- NQF : None
- Quality ID : 420
NQS Domain
ECC
Measure Type
Outcome
High Priority Measure
No
Data Submission Method
- Registry
Speciality Measure Set
Primary Measure Steward
Society of Interventional Radiology