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CMS Measures

Comprehensive Diabetes Care: Medical Attention for Nephroathy

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening or monitoring test or had evidence of nephropathy during the measurement year.

Date Reviewed: March 29, 2019

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 prescription drug claims for antipsychotic medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).

Date Reviewed: November 4, 2018

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.

Date Reviewed: November 4, 2018

Angiotensisn Converting Enzyme-Inhibitor (ACE-I) or Angiotensisn Receptor Blocker (ARB) Therapy--Diabetes of LVSD (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. 

Date Reviewed: November 4, 2018

Appropriate Follow-Up Interval for Nomral Colonoscopy in Average Risk Patients

Percentage of patients aged 50 years to 75 years 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.

Date Reviewed: November 4, 2018

Appropriate Use of DXA Scans in Women Under 65 Years Who do not Meet the Risk Factor Profile for Osteoporosis

Percentage of female patients aged 50 to 64 without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period.

Date Reviewed: November 4, 2018

Assessment of Hepatitis B Virus (HBV) Status before Initiating Anti-Tumor Necrosis Factor (TNF) 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.

Date Reviewed: November 4, 2018

Breast Cancer Screening

The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

Date Reviewed: November 4, 2018

Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

Percentage of adults 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.

Date Reviewed: November 4, 2018

Diabetes: Eye Exam

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.

Date Reviewed: November 4, 2018

HIV Infection Screening

Percentage of patients 15-65 years of age who were tested at least once for HIV.

Date Reviewed: November 4, 2018

HIV: Viral Load Suppression

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.  A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.  

Date Reviewed: November 4, 2018

Ischemic Vascular Disease: Use of Aspirin or Another Platelet

The percentage of patients 18-75 years of age who had a diagnosis of ischemic vascular disease (IVD) and were on daily aspirin or anti-platelet medication, unless allowed contraindications or exceptions are present.

Date Reviewed: November 4, 2018

Medical Attention for Nephropathy

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening or monitoring test or had evidence of nephropathy during the measurement year.

Date Reviewed: November 4, 2018

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.

Date Reviewed: November 4, 2018

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.

Date Reviewed: November 4, 2018

Tuberculosis (TB) Prevention for Patients with 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.

Date Reviewed: November 4, 2018

Zoster (Shingles) Vaccination

The percentage of patients 50 years of age and older who have a Varicella Zoster (shingles) vaccination.

Date Reviewed: November 4, 2018

Closing the Referral Loop: Receipt of the 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

Date Reviewed: July 21, 2018

Falls: Screening, Risk-Assessment, and Plan of care to Prevent Future Falls

This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates:
A) Screening for Future Fall Risk: Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months
B) Falls Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
C) Plan of Care for Falls: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months

Date Reviewed: July 21, 2018

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who received the following.
- Initiation of AOD Treatment. The percentage of patients who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
- Engagement of AOD Treatment. The percentage of patients who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.

Date Reviewed: July 21, 2018

Sub-1 Alcohol Use Screening

Hospitalized patients 18 years of age and older who are screened within the first day of admission using a validated screening questionnaire for unhealthy alcohol use.

Date Reviewed: July 21, 2018

SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB 2a Alcohol Use Brief Intervention

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay. Those who refused are not included.

Date Reviewed: July 21, 2018

SUB-3a Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included.

These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]).

Date Reviewed: July 21, 2018

TOB-2 Tobacco use Treatment provided or Offered and the subset measure TOB-2a: Tobacco Use Treatment

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom tobacco use treatment was provided during the hospital stay, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment during the hospital stay.

Date Reviewed: July 21, 2018

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.

Date Reviewed: November 19, 2017

Adult major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: November 19, 2017

Adult Major Depressive Disorder: 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.

Date Reviewed: November 19, 2017

Adult Sinusitis: Appropriate Choice of 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.

Date Reviewed: November 19, 2017

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin with or without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis

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.

Date Reviewed: November 19, 2017

Adult Sinusitis: 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.

Date Reviewed: November 19, 2017

Annual Hepatitis C Virus 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.

Date Reviewed: November 19, 2017

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).

Date Reviewed: November 19, 2017

Avoidance of Antibioitc 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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 to take medications as directed; and Stewardship of patient resources.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Surgery 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.

Date Reviewed: November 19, 2017

Chronic Stable Coronary Artery Disease: 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.

Date Reviewed: November 19, 2017

Colorectal Cancer Screening

The percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.

Date Reviewed: November 19, 2017

Comprehensive Diabetes Care: Hemoglobin A1c (HgbA1c)

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.  

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

COPD: 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 a long-acting inhaled bronchodilator.

Date Reviewed: November 19, 2017

COPD: Spirometry Evaluation

Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented

Date Reviewed: November 19, 2017

Coronary Artery Disease: Beta Blocker Therapy - Prior Myocardial Infarction 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 myocardial infarction or a current or prior LVEF <40% who were prescribed beta-blocker therapy.

Date Reviewed: November 19, 2017

Dementia: Caregiver Education 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

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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 in a 12 month period

Date Reviewed: November 19, 2017

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

Date Reviewed: November 19, 2017

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

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Depression Remission at Twelve Months

Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve 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 twelve months (+/- 30 days) are also included in the denominator

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Diabetic Foot & 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.

Date Reviewed: November 19, 2017

Diabetic Foot & 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Functional Status Assessment for Patients with 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction

Percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting or at hospital discharge

Date Reviewed: November 19, 2017

Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction

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.

Date Reviewed: November 19, 2017

HIV/AIDS: Sexually Transmitted Diseases - 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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 600mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year.

Date Reviewed: November 19, 2017

Influenza Immunization

Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.

Date Reviewed: November 19, 2017

Ischemic Vascular Disease: All or None Outcome Measure

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

Date Reviewed: November 19, 2017

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

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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 of age
Total Rate: All patients 18 years of age and older

Date Reviewed: November 19, 2017

More Than One CT Scan Within 90 Days for Chronic Sinusitis

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

One-Time Screening for Hepatitis C Virus 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Osteoarthritis: 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Overuse of Neuroimaging for patients with Primary Headache and a Normal Neurological Evaluation

Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Pneumococcal Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Date Reviewed: November 19, 2017

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up

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

Date Reviewed: November 19, 2017

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

Referral to 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.

Date Reviewed: November 19, 2017

Screening for Hepatocellular Carcinoma 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.

Date Reviewed: November 19, 2017

Screening for Osteoporosis for Women 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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 19, 2017

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.

Date Reviewed: November 17, 2017

Afib and Aflutter: Chronic Anticoagulation Therapy

Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation 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 .

Date Reviewed: March 19, 2017

Prescription of HIV Antiretroviral Therapy

Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

Date Reviewed: November 7, 2015

Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity

Percentage of patients aged 18 years and older with a diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: April 27, 2015

Assessment and Classification of Disease Prognosis

Percentage of patients 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.

Date Reviewed: April 27, 2015

Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy for Rheumatoid Arthritis

The percentage of patients 18 years and older by the end of the measurement period, diagnosed with rheumatoid arthritis and who had at least one ambulatory prescription for a disease-modifying anti-rheumatic drug.

Date Reviewed: April 27, 2015

Rheumatoid Arthritis: Assessment of Disease Activity

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.

Date Reviewed: April 27, 2015

Rheumatoid Arthritis: Functional Status Assessment

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.

Date Reviewed: April 27, 2015

Rheumatoid Arthritis: Tuberculosis Screening

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who have documentation of a tuberculosis (TB) screening performed within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).

Date Reviewed: April 27, 2015

Heart Failure: Left Ventricular Ejection Fraction Assessment (Outpatient Setting)

Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12 month period

Date Reviewed: November 26, 2014

HCV Genotype Testing Prior to Treatment

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment (paired with NQF 0395)

Date Reviewed: July 26, 2014

Hepatitis C Ribonucleic Acid (RNA) Testing Before Initiating Treatment

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment (paired with NQF 0396)

Date Reviewed: July 26, 2014

Hepatitis C: Antiviral Treatment Prescribed

Date Reviewed: July 26, 2014

Hepatitis C: Counseling Regarding Risk of Alcohol Consumption

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period

Date Reviewed: July 26, 2014

Hepatitis C: HCV RNA Testing at No Greater Than Week 12 of Treatment

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at no greater than 12 weeks from initiation of antiviral treatment

Date Reviewed: July 26, 2014

Hepatitis C: Hepatitis A Vaccination

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A (paired with PQRS 184)

Date Reviewed: July 26, 2014

Hepatitis C: Hepatitis B Vaccination

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B

Date Reviewed: July 26, 2014

Hepatitis C: Testing for Chronic Hepatitis C - Confirmation of Hepatitis C Viremia

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed

Date Reviewed: July 26, 2014

HIV/AIDS: Adolescent and Adult Patients who are Prescribed Potent Antiretroviral Therapy

Percentage of patients with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit: aged 13 years and older who have a history of a CD4 count less than or equal to 500 cells/mm3; aged 13 years and older who have a history of an AIDS-defining illness, regardless of CD4 count; or who are pregnant, regardless of CD4 count or age, who were prescribed potent antiretroviral therapy

Date Reviewed: July 26, 2014

HIV/AIDS: CD4 Cell Count or Percentage Performed

Percentage of patients aged six months and older with a diagnosis of HIV/AIDS, with at least two CD4 cell counts or percentages performed during the measurement year at least 3 months apart

Date Reviewed: July 26, 2014

HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, who had at least two medical visits during the measurement year, with at least 90 days between each visit, who are receiving potent antiretroviral therapy, who have a viral load < 200 copies/mL after at least 6 months of potent antiretroviral therapy

Date Reviewed: July 26, 2014

HIV/AIDS: Medical Visit

Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS, with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit

Date Reviewed: July 26, 2014

HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis

Percentage of patients aged 6 weeks or older with a diagnosis of HIV/AIDS, who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis

Date Reviewed: July 26, 2014

Dementia: Counseling Regarding Risks of Driving

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period

Date Reviewed: April 7, 2014

Dementia: Screening for Depressive Symptoms

Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period

Date Reviewed: April 7, 2014

Staging of Dementia

Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered DVT prophylaxis by the end of hospital day two

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Screening for Dysphagia

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care

Date Reviewed: April 7, 2014

Stroke and Stroke Rehabilitation: Thrombolytic Therapy

This measure captures the proportion of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well for whom IV t-PA was initiated at this hospital within 3 hours of time last known well

Date Reviewed: April 7, 2014

Sleep Apnea: Positive Airway Pressure Therapy Prescribed

Patients who were prescribed positive airway pressure therapy as a proportion of all patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea

Date Reviewed: April 8, 2013